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APPLICATION FOR SANITATION PERMIT Permit No. ------/.------I.._---- � �t (Complete in Duplicate) —� Date Issued -----� ---_----- 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 LOCATIO ------ --- Owner's Name----C---/0-,L-'---------- - --------------------------•-------------------------- ----------------- ------- -------------- Phone------------------------------------ Address 'Ce / ------------ --------- -------------------------------------------------------------------------------*------..---•--••--- ors Name_. --- All --- --- -----------------------------------------•-- Phone-------•----------•------ --------- Insfallation will serve: Residence 2--A"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_- Number of bedrooms _S__ Number of baths --Al-- Lot size ------/_ _______________________________- J Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E❑ Previous Application Made: Yes ❑ No Z-' New Construction: Yes ❑ No 2�F A/VA: Yes ❑ No 2 — TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) a�eptic 'rank: Distance from nearest well_________________Distance from foundation----.---------------Material_-__________-_--_____-______________.__,-__.-. T,..r No. of compartments--------------------------Size-------------------------------- depth--------------------- ----Capacity---------------------- Dispo I Field: _, Distance from nearer} well-_-f-19_-._Distance from foundatic,041-_______-Distance to nearest line---'Y ______ 401 Number of lines-------/--------------- -------yy_Length of each line--------------- ------------.Width of trench-----------�..__�------------____-- Type of filter material - !vDepth of filter material____I �r__-_-_Total length_________ e__--------------- 4, _____ ___ __ Seepage Pit: Distance to nearest well__1_ _._________Distance frgmpp__foundation__ '^_ __+__._..D•s�f,ce to nearest lot line__3�__.._,_. ge Number of pits-------- Lining material/E /f�L��Size: Diameter--- Deptn___ + 7--_-____-______ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material__-__._.___________________________ ❑ Size: Diameter------------------------- ------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------- El Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and -----------------------/or repairing (describe]-----------------4 ------__- F ---------------------- ---------------- ----------------------•------------------•--------------------------------•--------------------•------------•-----•----------------------------------------=--• ------ ---------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------•------------------------------- 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. ----- ------------ �+4 Contractor) (Signed) By:--------------------------------- / -------------------------------------------------{Title) =1��- ---------- - --------- -- (Plot plan, showing size of to , ocation of system in relation to wells, buildings, etc., can be placed on rever side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ---- - ------- ------------------------------------------•--------••-------------- DATE-----� REVIEWED BY--------------------------------- { DATE _1 -------- BUILDING PERMIT ISSUED t- – – ;. DATE ------------------------------------ -- Alterations and/or recommendations: ._.. ---------------------------------------------•---------... ---•--- r�, = -•------------------•-------------------------•----------------------•- ----------------------------------------------------------------------------------- ---•-----------------------------------•----------------- ------------------------- -- --------------------------------------------•-----•-••---------------------------------------------------------- t FINAL_ INSPECTION By.• "j --------------------- Date-----r r -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 forth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M Revised 1.57 VP.CO-