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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issued _. __Y --------J� 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 kvith County Ordihpnco No. 549. W'- JOB ADDRESS ND LOTION--- v "°' :"4 r. - 1 ~ �` � . d 0 Owner's Name- - -- --- ----''---- -- --- ----------- Phone-- -7_--�---I-------------- Address---------------- - -r - . 474 _ Contractor's Name_ r� ----------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j_____ Number of bedrooms _�L__ Number of baths ____L Lot size __�_rd_--- __I_a�~t_7____________________________________ Water Supply: Public system ❑ Community system ❑ Private 9 Depth to Water Table __iJ_._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam'U Clay Loam p Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ NI)s New Construction: Yes ❑ NoA TYPE OF INSTALLATION AND SPECIFICATIONS: �y (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) .Y. l Septic Tank: Distance from nearest well_________________Distance from foundation------------------- Material_________:___________________________---_--.-. ❑ No. of compartments-------------------- ----Size--------------------------------Liquid depth--------------------------Capacity----------------------- i D�iposal Field: Distance from nearest/we31__e�1+0_._.__._Distance from foundation__ ---------.Distance to nearest lot line_______________ Number of lines_______1_____._y_^ ____.___ __Length of each kne_____ .�- Width of trench____��_'-_______________________ Type of filter - --Depth of filter material------/--�..........Total length ---- s"______ ------------------------ 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-----------------Distance from foundation--------------------Lining material-------------------------------------- F1 Size: Diameter-------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ D Distance to nearest lot line- yc. Remodeling and/or repairing (describe): /''Z -- -- ----------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Paws, and rules and regulations of the San Joaquin Local Health District. (Signed) --------------------------------------------------------------------------------- {Owner and/or Contractor) 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 - ---------------- ---------------------------------------- DATE--_`F' _%r_,3 REVIEWEDBY------------------------------------------------------------------------------------- --------------------------------------- DATE------------------------------------ BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------•------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------- ---------------------------_------------------------------------------------------------------I-------------------------------------------------------------------------------------------------- ------------------------------------------ -- --------------------- ------------------- -iJ 4 FINAL INSPECTION BY:- --------------------- -- � � Date / �� --- --- - ----------------------•-------------- SAN JOAQUIN LOCA EALTH 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 B-51 Revised W-2100