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T q • APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) G S�� - Date Issued ---- j ___ Applica+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 AN CATION---- ' f�rl�--------�o------- - --- ------ -------------------------•--------------------------- Owner's Nam �� €�1 =----'-----� Phone. Address_ * , --- =------- ----------------------------------------------------------- •------ ------- -•• •• - ---------------= ------- q Contractor's Name-- _---- -----•------- ---- '4•(- � ------------------------- -------------------------------------------- Phone_ �_C��? 1 Installation will serve:. Residence dr ment House ❑ Commercial ❑ Trailer Court. ❑ ' Motel ❑ Other ❑ Number of living units: ___-_ Number of bedrooms _Number of baths -f ----- Lot size --�-�d---------A---�---- ----�---•--•---------•- Water Supply: Public system �mmunity system ❑ Private ❑ Depth to Water Table, ?— ft. Character of soil to a depth of 3 feet' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ ,No 4n- 'New Construction: Yes ❑ No-�R- TYPE OF INSTALLATION AND SPECIFICATIONS: (No 'septic tank or cesspool permitted if public sewer,is available within 200 feet.). Septi Tank: Distance from nearest well--------- Distance from foundation___________________.Material-_-_________.___________.._._-_______.________. .w. No. of compartments------------- ------------Size------••------------- " ' "Liquid'depth---------------------- Capacity---------------------- . l Disposal Field: Distance from nearest well------ ......Distance from foundation_____________..-----Distance to nearest lot line_______--_--_-_-- .- Number of lines-------------------------------" -Length of: ach line------`----------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of;filter •al------------------------Total length------------------------------------------ Seepage rom ounclati Seepage Pit:- Distance to nearest welt ... ._.>/�..------ .Distance to nearest lot line___f_�______ Number of pits--------I-.----------Lining mater' , Siz Diameter__��-e.____-__Depth--24--t--------------- Cesspool: Distance from nearest well." .__--___.__-__Dist ce fr n ation-------------- material-------- ______---__________ ❑ Size: Diameter----- --------------------------------Depth-=`=------ -----••--------- - ----------------Liquid Capacity---------------------------gals. \� Privy: Distance from nearest well--------------y---------------:-----------------Distance from'`nearest building----------------------------------------- ❑ " Distance to nearest lot line._'._A_._____--_____.__-_ _ } --- . Remodeling and/or repairing`'{describe}-------------------- - - -__----_- --_------------------------•-------- -- y I -----------------------------------_------------------------_____-----------------------------------------------------_-------_-------------------------------------__------------------------------------------------------- __ ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances;S law end pules and ' egulatioris of the San-Jdaqu'in Lacal Health District._ r- [Signed) = --- - ----`�-- ----- ...... ---- -- ----------------------------------------------------- - intractor) By:.-. (Title)Y• =--------------------------------------- i --- ----- (PloV plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1=0R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--- ---------:-------- -- - - --------------------- DATE.---- - ---------------- REVIEWED BY { `- DATE. .......---�- - .. ------------------............ BUILDING PERMIT ISSUED--------------- ... DATE-------------- ---- - ---- Alterations and/or recommendations:-=--------- -------------- - �i-� .................. I -------------------------------•----------•---•-------------------------------------------- ------------•-------------------------------------------------------------......._ ---------------------__--•-••-----•-- ----------------------------------- ----------- -----•--------------------------------------------------------------------------------------------------------------------------------------------------__------------------ - ----------- ---------- -------- -------- -----------------------•--------------- ---------------------- -----------------------------------------------" -------------------------------------------------------------- J FINAL INSPECTION BY-- ------ -------------•---------------- Date___ - -----�• ]/-------- ----------------------------- .. f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Armoric-an Street 300 West Oak Street 132 Syoamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M. 145446 ATWOOD