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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �0 �.T% Date issued r.___-----_._ 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. JOS ADDRESS ND L• CAS IOI�f_-_-/R ------------5 ' ------------------------------------ Owner's, Name__ ! ` -�`== PhoneW"0 X Address1 !� ---- - -------------------•-----------------------------------•---------------•------------------------------------------------------- ' Contrac:tor's Name-- ----- ----- ---------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Zpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Plumber of living units: ---'.- umber of bedrooms -_�_ Number of baths -------- Lot size )(J-0----- --o Water Supply: Public system Community system fl Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand � E]Gravel Sandy Loam Clay Loam F-] Clayp Adobe 2/Hardpan F_ Previous Application Made: Yes F-1No New Construction: Yes o ❑ 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-----------__--- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------------- Type of filter material-------------------------Depth of finer material----------------------- length---------------------- .-__-____-__---. Seepage Pit: Distance to nearest well-.- --------------Distance from foundation--------------------Distance to nearest lot line---------------- ❑ Number of pits--------------------_Lining material-----------------------Size: Diam ter)-------_-----_ __ Depth---!-- _--.:---------------- �-. L11 Cessp r1: Distance from nearest ell------ --------- - Distance from f undation-_------ - Lining material--- ' -- Size: Diameter---------------------------- ----Depth-------------- ------ - ---------------------Liquid Capacity-------------------- ------gals ,r Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------- __---_------.-. ❑ Distance to nearest lot line- 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 Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed).- s�. -- � - •�r..� -------------------- ----------------------------------------------------------------(Owner and/or Contractor) r 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 _________________________________-_-__----------- -- ----------------------- ----------------------- --------------------------------- REVIEWEDBY - -------------------------------------------------------------------- DATE--------.;. - BUILDING PERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE---- Alteration nd/or recommendat - ons: =-- , p: e ate _ = ye -t -----------------------------------------------------------------------------------------------•----_-_------_-__---- r ------------- ----------------- --------------------------------- --_-_______•-_---------------------------------------- ------------- f 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, Cafifornia Lodi, California Manteca, California Tracy, California ES--9-2M 9-S1 Revised W-2100 r