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APPLICATION FOR SANITATION PERMIT Permit No -d__-__:_ \ (Complete in Duplicate) Date J_ssuecl Ap icatior�is h reby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T s application is made in compliance with County Ordinance No. 549. j JOB ADDRESS AND LOCATION_____ ._ __t `___ _____ _ _F'= __`t -------------------------------------------------------------------------------------------- Owner's Name.. _ _ "_p �s�-�C'G® ® �` Phone E1 Addressat e ` ".-------� -------------------------•-------------------------------------- ----------------------------------------------- Contractor's Name------ .� ._ - / Y �"B ' . `r' �` �° ' Phone. -7------------------ ------ Installation will serve: Residence R Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.----- Number 'of bedrooms __ Number of baths _1____ Lot size Water Supply: Public system ❑ Community 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 ❑ New Construction: Yes ❑ No ❑ TYT�E 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 foundation_____________ ____Material.-_____:___:_____________-______-:_________. ❑ No. of compartments--=-----------------------Size-----------•-1------------------Liquid depth-------------------------Capacity----------------------- Disposal Field: Distance from nearest well_"_ems_ - _Distance from foundation----YO!_------Distance to nearest lot line-_/10______• Number of lines______________ °° ® �_�F____________Length of each line_____,/E;3_j�___��,_____.Width of trench___„2_� ____________________ _ Type of filter material-4i_-__5o.-R-Depth of filter material-__ -------Total. length_,-----,/_D0P___________________________ Seepage Pit: Distance to nearest well__--------------------Distance from foundation--------------------D`istance to nearest lot line_--__:___________ ❑ I 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---------.-----------._______.,__- ❑ Distance to nearest lot line- ------------------------------------------------------------------- Remodeling aQd/or r pairing (describe) >� ,/ `¢ 2.�x� ?«t.�---------------------- ------ � t ,� � _. .__.__.,t__ __ _______ (ff /4� j i ______________._-__.'�.c?____.___________.._____._______________________ _._________.___.______-_________________________________._.___.___.__-____________________.___________-______________________-_____________________ ________________________________________________________________________________________________________________________________•___.--______________-___-__-_-_______________-_____--___________-__________________-_-_______ 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. (Signed)--•--•. ' ._._i E '- A/R/ - i!°e ' - �Owner /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). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 02- ----------------------------------------------------- DATE REVIEWEDBY------------------------------- -------------------------------------------------------------------------------- DAT - ---------- BUILDING PERMIT ISSUED---------------------------- --------------- ----- ----------------------------------- DATE_ -- -------- ---------- Alte ations a d or reco endatiQns° _ 4. I ----- -- ----------- ------------• -------- ---• --------- .w ___. ------. --.._ r - - .___--- -' f � ----- --- --------- --- - ------------------------------------- -------------- -------------------------- ------------------------------------------ ----------------------------------- ---------------------"--- --------------------- -------- FINAL INSPECTION BY----------------- �----- -------------- Date------ f .-=------ 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 10-52 Revised W-2100