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APPLICATION FOR SANITATION PERMIT Permit No. r _ (Complete in Duplicate) Date Issued 02-7— !lPt7 r Application is hereby made.to the San Joaquin Local Health District for a permit to const uct a�d i all�he work herein d scribed. This application is made in mpliance with County Ordinance No. 549. /1/c� Y7� V i I–t1 r l JOB ADDRESS AND LOCATION• --------------------------- • ' X Owner's Name------------ r \/\ r Phone ----------------- ti Address----------------- rJ -------- P � a Contractor's Name---------------- ---------------------------------------------- --------------------- - --- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Traill2e Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms . Number of baths /!_;/Cot size ___ lam___ ___— __ _ _ -------------- Water Supply: Public system ❑ Community system ❑ Private Ej 6epth to Wafer Table /7ft. 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: Yes [�rNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_____ -Distance from fours ation_ __f Q - Mater-i5�1--- U c Y e - ------------------------• - � No. of compartments---------7�----------Size------ - ;quid depth--------------------------Capacity-.-----_ --------- Disposal field: Distance from nearest well___j Distance from foundation__��istance to nearest lot h}�a fir___ Number of lines------------ ,_� __ fit_Length of each line-------�_�_b_ y____ ____ _[9 ______________ Type of filter material__ _-:_ _______Dep#h of filter material________CWidfh of trenc______`fotal length----- h________�_�__�___`_______.____ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------.------.Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter_----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________-_________________--____. ❑ Size: Diameter-------------------------------------- Depth - ---------------------- ------------------Liquid Capacity------ .._------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El ________-__________-__________-__ ____- ❑ Distance to nearest lot Iine-------------------------- ------------------------------------------------------------------------------------------•--•------- Remodelingand/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 regulations of the San Joaquin Local Health District. r (Signed) -- --- -----------------------------------------------------------------------------(Owner and/or Contractor) 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 ------ D Ry ----------- --------------------------------------------------I------------------ DATE------------------------------------- ! PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE- ------------------------------------------- Alterations and/or recommendations:---------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------•------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ------ 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-9-2M B-51 Revised W-210D