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APPLICATION FOR SANITATION PERMIT. Permit No. (Complete in Duplicate) Data 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 N 549. JOB ADDRESS AND LOCATION____------ Q-' __.______ C'" 6.LrE.��c.,.R,�_ ---------- Owner's Name----------- --,)A -------- --- -------------------------------------------------------------- Phone----------------------------------- Address--------------------------------------- Contractor's Name---------------------------(21 -----------:----------------------------------------------------------------------------•-- Phone----------------------------------- Installation will serve: Residence �partment House ❑ Commercial F] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I-----_ Number of bedrooms .__ __ Number of baths/___._. Lot size ___-.___- � -_ _ ---2 --•----- Water Supply: Public system �mmunity system ❑ Private 9,0'6epth 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 23-1 o ❑ New Construction: Yes 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-••-------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- E-1 Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- 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----------------------Lining material-----------------------Size: Diameter-----------------------Depth,-------------------------------- � Cesspool- Distance from nearest well-----------------Distance from foundation:---- ----_-_.Lining material_-.---_----.---__._____--_----_---- Q ❑ Size: Diameter------------- -----------------------Depth----•--------------- -----------------------------Liquid Capacity-------------- -----gals. Privy: Distance from nearest well---------------__�d.___ __. ___ ___-_.._Distance from nearest building � Distance to nearest lot line._._____-__________:�_------ UU 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 laws, and rules and regulations of the San Joaquin Local Health District. (Sign ------------- -------------------------------------(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---------- • ------- REVIEWED BY --- ----------------------------------------------- DATE---------------------- BUILDINGPERMIT ISSUED--------------------------------------------•----------- •--------- --------------------------------- DATE Alterations and/or recommendations---------------------------------------------- -------•--•------------------------- --------------•---------...-----------•-----------•-----------•------------ -------•--I------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------• ------------------------ ----------------------------------------------I----•------------------------- ---------------•----•-------------------------------------------------------------------------------------------------------------------------- -------------------------------------•-------•--------------------------------------.-----•------------------- ----------------------------------------------------------------------•--------------••-- FINAL INSPECTION BY:--------- --- Date_ - ------------------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100