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APPLICATION FOR SANITATION PERMIT Permit No. ._./ . 1 (Complete in Duplicate) IDate Issued Ap l)icafion 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 __;Ck04-_-.S_a} Owner's Name----- �------------------------------------------------ -------------------------------------------- Phone__- - ! ------ Address----------------------------------------------5a ----- Address----------------•-----------------------------5a-Ar Contractor's Name----------------------------5 a m - ------------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial p Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___-_ _ Number of bedrooms __ . Number of baths ________ Lot size ______ [o_-___ - -Q ______________________ Water Supply: Public system ® Communify system M Private ❑ Depth to Water Table -------- ft. x Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay D( Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No D� New Construction: Yes X No ❑ 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 foundation-------------------.Material ____._-_____________- ❑ No. of compartments--------------------------Size---------------------------- ---Liquid depth-------------------- --- Capacity----------------------- `V Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_-_-_------------� ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Q Type of filter material-------------------------Depth of filter material __.-_--.--------------Total length_.----_________-___..__________- Seepage Pit: Distance to nearest well----------------------Distance from foundation____________________Distance to nearest lot line _.. ❑ Number of pits-----------------pp----�---Lining`material-----------------------Size. Diameter,----------------------Depth.........._--__--__-___--_------ Cesspool: Distance from nearest well__!-0------Distance from foundation--- a____-Lining material__R�01_W4a4 ----------------------- �) , Size: Diameter- _� f__ QV.-4n -Depth------ ---•----------------------------------------Liquid Capacity....../&Z-O---------9 s. Privy: Distance from nearest well.__.-I_______________------_----------------------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 I WS, and rules and regulations of the San Joaquin Local Health District, (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 C_l~--z ----------------------- - REVIEWED BY --------- ---------------------- DATE------------------ ------------------------------------------ BUILDING 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 E5-9-2M 10-52 Revised W-2100