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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) y S�� Date Issued 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 AND LOCATION.- ��___/__(�1--I-_____- �- _ Owner's Name--------------- ------'-"... t r.: ------------ ----- --------------._ Phone--- -------AU_ Address------------------------------------ = Contractor's Name ' --------------- -•----------------------- Phone. _-4,f_40 Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel� ❑ Other ❑ Number of living units: ___�,- Number of bedrooms Number of baths /___ Lot size .__ tet____ --�_ _- ------------ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table1t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Z lardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ `Zew. � TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Tank ,. Distance from nearest well_____________ .._ ____Distance from foundation_______- _.______.Material______________-__._-__________________-________. ( - 7 No. of compartments-'------------------------Size...------------------------ ---Liquid depth---------------- ---------Capacity----------------------- osal Distance from nearest well---------------__Distance from foundation-.------------------Distance to nearest lot line_______---_______ e Number.of lines___ ---_._.,._Length of each line----------------------------- e v' •----------- ---- -Width of trench---------------------- ----------- ype of filter material_________ ____ Depth of filter material-----------------------Total length--------------- --------------------- Seepage ___.-_________ ___________.______-- See a e Pit: Distance to nearest well__ _ ' p 9 +----------Distanc fro found ation_e_�---___.Distance to nearest lot line.... ............ �r Number of pits________.-__..__.__Lining material_ it ----------Size: Diameter____._ ---Pa. Depth- _ Q A ------------ Cesspool: Distance from nearest well-----------------Distanfrom foundation--------------------Lining material-_-__-_____-__-_-----___.___-________. ❑ Size: Diameter------ ---------------------- --------Depth----•-----------------------------------------------Liquid Capacity- -------------------------gals. Privy: Distance from nearest well----------_------------------------..----------.-Distance from nearest building____.--------.___________________--__----. ❑ Distance to nearest lot line-- -------------------------- ----------------•--------------•------ Remodeling and/or repairing (describe):_ ' ____ -^l •_ _.---- ------ --:- '= - -------------- -----•- -------•------ ------------------•--••-------------------•------------------------------------------••------------ ---------••--- -------•------•--••------------- .. . --•------------------- ---------------------••-------------------------- --------I- I hereby ertify that I have prepared this pplication and that the work will be done in accordance with San Joaquin County ordinances, S a l�k_ wjanriles a d regulatio s of the San Joaquin local Health District. ----- __. (Signed) ----- ------- - ----- Contractor) --' -t./k By: ------------ r f (Plot plan, showing size of lot, location of system in relatio to wells, buildings, c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY- - ------- ----------------------- -------------------------------------------•--------------- DAT E.-- ------------------------------------------------------ REVIEWED BY ------------------------- ---------------- DATE----x-' ------------- BUILDING PERMIT ISSUED------------ Y -------------- -- -----. DATE---------V Alterations and/or recommendations:__ ______ - --------- ---------------------------••-------------------------------- z r -------------- ----------------------------------- ----------------------••--•--•--------- -------------------------- FINAL INSPECTION BY:------. ------ Date------ �`.-.'-- �� �� --------••------------ ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M i ' Revised W-2100