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APPLICATION FOR SANITATION PERMIT Permit No�� ,(Complete in Duplicate) 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 wi�(th/ County Ordinance No. 549. JOB ADDRESS AND LOCATION ------ -J -- I /--------�V.-�- f 12 0 u _------------------------- r ----------- - Owner's Name -� `s - --- U � ! 1- Phone__. - C� l 59 Address----.... ---•-----------------------•-- Contractor's Name ------------------------ ----------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units: ________ Number of bedrooms - Number of baths _f____ Lot size ___-______Q_.___/_Z O_ Water Supply: Public system & Community system ❑ Private ❑ Depth 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 ❑ 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: Distance from nearest well --- (--'"- ._ Distance from foundation___ �Q_A__._- Mat�jrial__ C/7f No. of compartments__-__._�--______._Size___a:/_K31- _ Liquid eth _ -------------------------- Capacity ------ s ------ d_____ Dis os Field: Distance from nearest wellDistance from foundation----_�Q__�___.Distance to nearest lot line ____-4 Number of lines--------------- -'i!jj -- Length of each line---------- �-- ___-.-.Width of trench -------- 24z---'�__ Type of filter material _ . Depth of filter material__--:___�_s '_Total length -------- __________� �1-__- 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 ----------------- from foundation --- .......... ------ .Lining material_____._--____-_____._________.______ ❑ Size: Diameter ---------------------- ---------- -----.Depth ----------------------------------- , --------------- Liquid Capacity --- 911s. Privy: Distance from nearesf tveli"=:--------- -------- Y = .-__�-_.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,;Sfe laws, and rules and regulations of the San Joaquin Local Health District(Signed}•--•---x'----r�i----------------------------------------------- (Owner and/or Contractor) Y� ---------(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------ �_. REVIEWEDBY --------------------------------------------- --------------- -----------------------------------------------•-- DATE -----------/.. BUILDING PERMIT ISSUED ----------------------- -------------------------------------------------------- ---------------------- DATE Alterations and/or recommendations recommend-a--t-i-o-•n--s- --------E- ms•-�-� -------------- --:-=-=---------------------- �.-�- ----- - ---------a --- --- --------------- ----------------- ------------- --------------- --- -- -- ____________f =- ::--- '___1- - 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 ES -9-2M : Revised W-2100