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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) rv� a Date issued ------ Applicaa-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with'County Ordinance No. 549. JOB ADDRESS AND LOCATI N________�/�z__--- ---- ................ Owner's Name. --------------------------- ---- ---- -------------------------------- ---------- Phone------------------------------------ Address -----�- -----, - Contractor's Name------------- - Phone _-- ----____-- _ --------- - - ._�- -- -------- A Installation will serve: Residence xlApartment House ❑ Commercial ❑ Trailer Court ❑ Motel Q Other ❑ Number of living units: /-___ Number of bedrooms _a__ Number of baths /_. Lot size _`3d ------------•----------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 4a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yesx No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted ifjublic� ,sewer is available within 200 feet.) Septic Ta Distance from nearest well_(U cam_Distance from foundation____A--------Matterri�_ �_el _ -- . [/ No. of compartments._____._rC2____________Size__ ---Liquid depth--------7.__cr� _._Capacity__.. dQ__ Disposal Field: Distance from nearer$ wefi- -Distance from foundation_Rd_-______-.Distance to nearest lot line_____S._�__ Number of lines___.__l_________-_- --------Length of each line----, -_______________Wid#h of trench.____a ��_________ Type of filfer materiaLsf/_ __! n _Depth of filter material---..__1/-/ - �___Total length------------------------------------------ Seepage _-.-.__�Q__�_.____________________ Seepage Pit: Distance to nearest elL.__«l / Distanc r �fp ndation__..."7.4_�_.. a e,)o nearest lo_fline__ad_�__ Number of pits.-... _---_____Lining material__ _ l-C -! _.Size: Diameter.____ ....__Depth---f�_S__________________ Cesspool: Distance from nearest well-----------------Distance from founda#ion--------------------Lining material------------------------____________- ❑ Size: Diameter-------------------- ----------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----.------------- ----------Distance from nearest building------------------------------------------ 11 Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------- ----------------- Remodeling and/or repairing (describe):---------------------------------------------------•------------------------------------------------------------------------------------------------------ -------------------------------------------------------------•-------•-•-------------------------------•---••-------------•--- --------------------------------------- •--------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------•------------------------------•---•--•--------_----------- -•--------- ------------------------.-.----•-------------------------------------------------------,---•------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, laws, and rules a d- egulations of + e San Joaquin"Local Health District. Si ned , -- (Owner and/or Contractor ZAiBy:-------•----••---------- --• •--- -- --------- (Title} {---- - -' (Plot plan, showing size of lot, location of system in rel on to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- ----------------- ---------------------•-•-•-------------- DATE.__.C_ --- -- -------- -- REVIEWEDBY ---------------------------------- ---------------------------- DATE----------- ------ BUILDING PERMIT ISSUED - DATE Alterations d,J recti mendations• __. _ ____ _ --•_--_----- -----_-_---_-_----•--•-------- _F _ __ ___�- .._. ----------- ___ __ _ ___ _ _______________ _____________________________ _ j ----}----- -- - -•----------- -------------- ----------------------------------- •- ------ -- ---- FINAL INSPECTION BY:----- -------- --------1---------- Date-------� - r-- - ----------��7------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California �� ES-9-2M ; Revised W-2100