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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application 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. _ q � JOB ADDRESS AND LOCATION-------------------/S S f-------------$!t) Y t Owner's Name_____________________ 4 a_!►'�C!Y'-- -------- -- ---------------- --------- Phone------------------------------------ Address---------------------------------------------------------------------------------------- Contractor's ----------------------------- - Address--------------------------•-------------•----------------------------------------------- Contractor's Name------•---------------•------------------------------------------s- ------------------------------------------------------ ----- Phone----------------------------------- --- Installation will serve: Residence J] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms __--.f_. Number of baths J_____ Lot size ----------J�---/Ald---------------------------- Water _'___________________ ____Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. a 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'❑ TYPE OF INSTALLATION AND SPECIFICATIONS: .(No septic tank or cesspool permitted if public sewer is available within 204 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_______-___.-. -- SA ❑: Number of lines-----------------------------------Length of each line------------------:-----------Width of trench----------------------------------- Type of filter material_________________________Depth of filter, l- materia -_--_---_..__—____T _ Total length__--_--_.- -__ �h Seepage Pit: Distance to nearest well________________--_--Distance from foundation--___-..___--____-Distance to nearest lot line__--__________.._ ❑ Number of pits----------------------Lining material------------- -------Size: Diameter------------------ ----Depth--------------------- - i Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------ El Size. Diameter--------------------------- ----------Depth--------------------- -----------------------------Liquid Capacity-,-,------------------------gals. Priv Distance from nearest vrell___________________�__4--- --------------------Distance from nearest building------------3-0----_______--____-_-.-. ' Dis4ance to-o nearest'lof line--"- --=--=--=------- f I Remodeling and/or repairing:!(describe): --•------•---------------------------- -----------i---------••-----------•-----------------------------------------•----------------- ------------------------------ ------------------•---------------------------------- fr ----------------------------------------------------------------------------- ----------------------------------------------------- – -------------------••--- ---- ------------------ -• -- -----------I--- ---- 1 - --------------------------------------•------------------------------------------------------------------------------------------------------------------------ - ------ I 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. f (Signed)----------------------- ------------ -----• - (Owner and/or Contractor) BY: -•• rY (Title)------------------------------------I—'------------------ (Plot plan, showing siz"p�flo;_' ation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------ ------ ,e( DATE--------- ' REVIEWEDBY--------------------------------------------- -------------- - ---/-------- -------------------------------------------- DATE--------- - ----------•--------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:------------------------------ --------------- ---------------------------------------•---------------------------------------------------•------------------ - -------------------------------------------------------------------------------------------- ------- ---------------------------------------------•----------------------------••--------------------------------•--... ---------------------------------•-•---------- --•---•------- ------------------------------------------------------------------------------------------------ ---------------••----------------------•----•---•-••---•-------------------------------------- ------- ------•-------------- 1 FINAL INSPECTION BY:........---------- Date------------ .--- � -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M T-52 Revised W-2100