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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued V-/� Application 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 LOCATION---11 S T- ff Gt,./Vat j "t r D-- Owner's Name---------------- ►__ �. ( -CJ- .....j_ ------------------------------- - ------------------------------------- Phone 'S ----------------- Address---------------------- ('"TsC! (i -------------------------------------------- Contractor's Name---------------------------------- ----- -d-11- -------------------- Phone------------ --- --------------------------------------------------- ------------�------ ---------------------- Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _ Number of baths ___l___ Lot size __________ _________________________ Water Supply: Public system ❑ Community system;K Private ❑ Depth to Water Table ________ ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [X_ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - J Septic Tank: Distance from nearest well-----------------Distance from foundation----------------.__.Material_-----__ --______---________________________-__. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material_________________________Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to' nearest lot line----------------- El Number of pits---------------- -----Lining material--------------.--------Size: Diameter------------------------Depth------------------•_------------- r �0� Liu Dr 1 Cesspool: Distance from nearest well__ '�6____"__Distance from foundation"_-- _._-_-"_______.Lining material"__-________________ ________"-_____. Size: Diameter---S CP--------------------Depth-------------�0-----------------------------------Liquid Capacity-----•-;443;-`; -----gals. Privy: Distance from nearest well_____________________ ---------------------------Distance from nearest building____-_________.----_---__-__-_____-_--_. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):___ ___________ - ------------------ - -,---------- -- ---------------------------------------------------------------- -------------------------------------------- ---------------•--------------------------------------------------•---------------------------------------------"-------------------------------------------------------------- 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 regulati of the San Joaquin Local Health District. O Si ned------ = ------------------------------------------------------------------------- wner and/or Contractor ( g ( an / ) 1 By:------------------------------------------------------------------------------------------------------------------------------------(Title)-------------------------------------------- ------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- _-_____ _______-- _-- DATE--------------- -_ BY -- ----------------------- DATE BUILDING PERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE--------------------------------------------------- Alterations and/or recommendations----------------------------------------- ----------------------------------------------------------------------•-----------------.---------------------------- ----------------------------------------------------"-----------•----------------------------------------------- ------------------------------------------------------------"------------------------------------------------ ------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY--------- -- ---- "`_j '' Date w SAN JOAQUIN LOCAL HEALTH DISTRICT ' f 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 8-51 Revised W-2100