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APPLICATION FOR SANITATION PERMIT Permit No. --- _�- -.�__------ (Complete in Duplicate) Date Issued ---lil-!A-J-a J-- 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. JOB ADDRESS AND LOCATION... --- - -----�%y---.------ ------- Owner's Name ---------- ------------------------------------------ -------------------- Phone Address1 .....�4 ----------------•------------------ -----••---------- Contractor's Name --- -- ------------- --- -------- ' ------------- - ---- Installation will serve: Residence 94—Aparfinent House ❑ Commercial ❑ Trailer.Court ❑ Motel ❑ Other ❑ r Number of living units: --I__ Number of bedrooms _ - Number of baths j---_ Lot size -_-_4J-----X_-X-_QRs-------_---_ -------------- - Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table 110 ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ Noti 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-••---------•---------- Diisspoossal Fieicl:w Distance from nearest well__--------------Distance from foundation--------------------Distance to nearest lot I line----------------- � Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- `& Type of filter material-------------------------Depth of filter material___----.---___-_-_-_.-Total length---------------------------------------.-- Seepage Pit: Disfance fo nearest well_/, fA*-14-----Distance rom fo dation---- �.�..Distance to nearest lot fine_-�_---._. A— Number of pits-------�------------Linin material- ` _-- Size: Diameter_ ------------ ' .. Cesspool: Distance from nearest well-----------------Distance from foundation----- ---.----------Lining material-_.---- _-_ ----_.---_----------. ❑ Size: Diameter--------------------------------------Depth-------------- -------------------- --------------- Liquid Capacity----------------------------gals. O i Privy: Distance from nearest well __--.---__-_-;-----------------------------------Distance from nearest building------------------------------- ----------- ❑. Distance'to nearest lot line-------- ---------------------------------------------------------------- -------------------------------------------------------------- t Remodelingand/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. (Signed)..--� --- -±----- -/------- - --- --- --------- - ----------------------------- Contractor) --- By.- '" - --------------------------------------------------ITitle)- (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--------------------------------------------------• ,l4 -- ---------------------------- DATE---------- REVIEWEDBY------------------------------- ------------------------------------------------------------------------------------------- DATE DATE--- ---•---•------ BUILDING PERMIT ISSUED-------------------------------------------- •-----------------•-----------••---------------•---------• DATE-----•------------------------------------ ----------------- Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------------- ------------------------------------------ .. -----•--------------------------------------------------------------------------------------------------------------------------------------- ----------------- ---------------•-------••-----------•----------• ----------- --------------------------------- ------------------------- - ----------------•---------------•------------------•--------------•------•--------- ---------------------------------- f -•---- FINAL INSPECTION BY:.. Date ii�-a----------------------------------- 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 ; ' Revised W-2100