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APPLICATION FOR SANITATION PERMIT Permit No=?. 17___._ (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. JOB ADDR SS AND LQCAT ON___�__ _ I__.�_. ..... .- ------- --- Owner's Name_ ------ f ------------------------ ------------------------- Phone---------- -----------•--•-- Address-------------- - ------------ Ol • Contractor's Name--- ------------ ----------- ------------------------------•---------------------------------------------------- -------------....__ Phone----•---------- � Installation will serve: Residence ❑ artment House [] Commercial [❑ Trailer Court ❑ Motel ❑ Other . Number of living units: ________ Number of bedrooms ________ Number of baths ---I--- Lot size ____..__ a__ -PDQ.---------------_--_ Water Supply: Public system ❑ Community system ❑ Private (K Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel J� Sandy Loam ❑ Clay Loam E] Clay [:] Adobe E] Hardpan ❑ Previous Application Made: Yes [-] No XNew Construction: Yes ❑ Nox TYPE OF INSTALLATION AND SPECIFICATIONS: VfJ (No septic tank or cesspool permitted if public sewer is available within 200 ferret.) Septic Tank: Distance from nearest well_r�. __Distance fro foundation_.,)d_______.Material-______ ____ ______.___-_ ___-.__ No. of compartments------- r-_-------Size__., _ __,,�j _Liquid depth_________ ____ _ Capacity____ _-0------ Disposal Field: Distance from nearest well___._.-.__-____Distance from foundation-------------------_Distance to nearest lot line. _____ ❑ Number o-i lines-----------------------------------Length of each line------------------------------Width of trench.---------------------------------- Type of filter material------------------------Depth of filter material---.-------------------Total length------------------------------------------ D Seepage Pit: Distance to nearest well_.v 6�_�'-Distance rpm foundation_____.-..Distance to nearest lot line__. ___ """` Number of pits______ -------------Lining material__ _ ^ ______--Size: Diameter_44,e��_,�.7 Depth----- -4-------------- Cesspool: __ Cesspool: Distance from nearest well----------------- from foundation------------------- maferia -- -______-_____.__ �- ❑ Size: Diameter---- - -------------------------------Depth---------------------- --- -Liquid Capacity Privy: Distance from nearest well-------------------------------------------------Distance from nearest bu0d;ng-------------------------------------- F1 Distance to nearest lot line---------------------- --------------------- Re odeYng or r, ring (describe)- 1l- /--. iF------- --------='`�`-- Y ------------------------------------ ----------------------------------•-------------------------------------------------------------••---------------------------------------------------••--------------------------- 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).......... --- ------�'' (Z.. ---------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:-•- i�� - - (Title)_fr?. _ - •'�-� (Plot plan, owing size of lot, loc� of system in relation to wells, buildings, etc., can be placed on reverse side e FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- ------- ------------------------------------------------------------- DATE----- VIEWEDBY----------------------------------------- ------- --------- ---- ---------- ---------------- DATE-------- -_!nXn_,,t- BUILDING PERMIT ISSUED---------------------------------------- - DATE /�1 1 -----A ------------------- Alterations and/or recommendations------------------------- -- -----------------------------------•-------------- ----------•--------------------------------------------------------------------------------- ---- -------------------------------------------------------------------•-----------•---------•------------------•--•--- ----------------I----------------•--------------- ---------------------------------------------------------------------------------------------------------------------------------------------------•-------- - FINAL INSPECTION BY:--------------------------- iDate --------- - 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 io-52 Revised W-2100