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p APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) sl �r Date Issued kA\plica{ion is hereby made to the San Joaquin Local Health District for permit to c n !! q p o struct and install the work here described. This application is made in compliance with CountyOrdinanceNo. 549. JOB ADDRESS AND LOCATION----- G -�Cl-t�_-_------- ------------------------------------------------------------------------------------------------------ Owner's -------------------------- ---------------------------------------------------------------------- Owner's Name '- ----- --___:_ ----- -----•------------------ Phone------------------------------------ Address----------- -----------------------------••----Address----------- ------ Contractor's Name--- � 2 Phone_Z,/--a� rZ 6 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑i Motel ❑ Other ❑ Number of living units: Number of bedrooms -; Number of baths --/-- Lot size _ __J�Q,r ....... ___ --------------------------------- a Water Supply: Public system Community system ❑ Private'❑- Depth to Water Table YO ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W Hardpan ❑ Previous Application Made: Yes ❑ No �-g' Now Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public server is available within 200 feet.)w. Septic Tank: Distance from nearesi weft_I Q4 --.-.-Distance from foundation—_!�O-----------Maf*al,,_ ® No. of compartments----------2;;�-----------Size_S- -GXXLiquid epth----- -----------,Capacity__ - --_ ________ Qd_ � Disposal Field: Distance from nearest well---tT7a.......Distance from foundation___. _ --------Distance to nearest lot line_______S _�_ 56 Number of lines______-- �_.-_ --------------Length of each line- r ! 3 � -3 r'.Width of trench-------1-... .________ Type of filter mate rial__Ae-9-_"--4r------Depth of filter material....a--- --------Total length------- k kf Seepage Pit: Distance to nearest weft----------------------Discarrlce from foundation------------........Distance to nearest lot line_______-_-__.____ ❑ Number of pits----------------k-----Lining material-----------------_-----Size: Diameter-----------------------Dept h--------_------------------_----- Cesspool: Distance from nearest well--------r---_Distance fromfonn ation_---__-----.-_-__.Lining materia!___________________________________ (� ❑ Size: Diameter------------------------------------- Depth-------•------------------ ----------------Liquid Capacity--- •-----------------------gals. V Privy: Distance from nearest well------------------------------------ -------_Distance from nearest building__--_---__.__.__--___________--------___. ❑ Distance to nearest lot line------------------------------- ------------------•----I----------- Remodeling and/or repairing (describe)---------- --------v ---- ------------------------------------------ -------------------------------•----------------------------- .._..-._-• ---------------------------•-•---------- ---------------------I ------ t------------ ------------------------------------------------------------------------------•--•------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) < ----/ •a ��-----4 ---------------------j,-- ---(O er and/or Contractor) G�BY: � ----------------------------------------------•-----•.-(Title)- - ------- - --------- (Plot plan, showing size of lot,.location o system in relation to wells,buildings,="etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY"_ i -------------------------- DATE------ REVIEWED BY-------•--------------' --- ----------------------------- ----------------------------- ------- ------------------------------ DATE------ BUILDING PERMIT ISSUED-ft ------------------------------------------------------ DATE Alterations and/or.recommendations--------------- ------------------------------- ------------------------------------------------------------- ------------------------------- --------•------•----------------------------•------------------------------------------------------------------------------- ------------------------------•-------------------------- ---------------------------- --------------------- -------------------------------—1-----------------------------------------------------------------------------------•-------------------------------•-------------------------------•--------------------------------------- -----------------------•---------------------------------------------------- ------- -----------------------------------------------— ------------------------------•--------------- ------------------------•-------------- ---------------- --------------------------------------- ----------------- ----------------•-------------- ---------------------------------------------•------•-------------------------------------•-- FINAL INSPECTION BY:. �------------ Date--------------------------------•--------� 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-4-2M Revised W-2100 •