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APPLICATION FOR SANITATION PERMIT Permit No. ... {Complete in Dupiicate) 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.a JOBADDRESS AND LOCATION-------- -------E.------ ....4 -... -.mac......__----------------------•-••-----__-_--------------------------------------- Owner'sName ------•-------- ''L:�- -------------------- - --------------------------------------- Phone-------------------_-------------- Address---------- -------...... ---------------------- QContractor's Name-----=- , -.......... "`" ��.�---5 P_ -a Installation will serve: Residence 14 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____(-__ Number of bedrooms _Number of baths ____/__ Lot size ------ ------------------------- Wafer Supply: Public system. Community system ❑ '-Private ❑ Depth to Water Table':______ ft. Character of soil to a depth of 3,feet: Sand ❑ Gravel F1Sandy Loam ElClay Loam Clay E) Adobe Hardpan E] Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank,or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: istance from -nearest well_________________Distance from foundation-________-- --------Material------------------------------------------------- ❑ o. of compartments---------- --------------Size--------------------------------Liquid depth-------------------------:Capacity--------------- -- Disposal Field istance from nearest well...._-- -Distance from foundation___. ___-.Distance-to nearest lot Gn /.-______. ® Number of liries____________/-__�,r-___ Length of each line------- _ ______.Width of trench_______-� * Type of filter material-___� ________ - epth of filter,material______1.-_____.-__Total length-__.____._ _✓ _______________________ /41 Seepage Pit: 'Distance to nearest well___ - -_-_Distance from foundation-----_44_--.__.Distance.to nearest lot Dine__ ______________ p Number of pits------/---------------Lining material---- Diameter-- - --------- Depth---- ,_-2 ------------------- N �' i ----------- Cesspool: Distance' from nearest`well=__"_:�"`_ 'Distance,from foundation ,_.____-- ...Lining material_________________________'__________. , __._Liquid Capacity----------------------------gals. ❑ Size: Diameter-----`-% -'-�----------'---------- Depth Privy: Distance from nearest well------------------__.--_ -.}__Distance from nearest building_____________________________._____---__. ❑ Distance to flearEStlOt'Ilne-T____--------=''--` -------------•'------------------- Remodeling and/or repairing (describe)---------- --------------------•------------•--•------- ------ ---------------••--------------------------------•---------------------------••--- ------------------------------------ y # r.: ------------------ -------- -- ------------------------------------------- ----•-••--------•-----•-----------•------------------ - -- - -- - - ------ - 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 eules and regulations of the San Joaquin Local Health District. r .- ---------------------------*---------------------{Owner and/or Contractor) (Signed) f - �- --------.'£`-=- By---s-----•----_ r .�= _ 9 !_. '''- '!d':. .---------•------=--'----- (Title) ,. [Plot plan, showing site of lot, location of system in relation to wells, 'buildings, efc., can be placed on reverse side]. j FOR DEPARTMENT USE ONLY _ APPLICATIONACCEPTED BY----------------- ------- -------- --------I-- -------------------------------------•-- DATE----- -------------------------------------- REVIEWEDBY-------------------------------- ------- - ------------------------------------------------ ------ DATE--- - - - ---------- BUILDINGPERMIT ISSUED-------------------------------- ------------ ----------------------•-------------------------- DATE.--------------- ------------4------------------------- Alterafions and/or.recommendations------------- ----- --__---------------------• -----.--_-------------- •... ----------- --- FINA---------- ---- --------------------- ----------------•------------------------------------------- ---- --------- ---- ,'S Date.. = ------�---------�'--�---••---------------- L -INSPECTION BY:�----- --- ---- ----------- 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-4-2M Revised W-2100