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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ' 7 6 � Date issued .. 7/--�_ pplicafion 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 Ordnance 549. f L CAT70Z ---;;.. JOB ADDRESS 1Q ' Owner's Name----f----------- !vz •-----•-------------------------------------------------------------- ------ Phone Address--- Contractor's Name ---- ----------- --------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial•❑ Trailer Court ❑ Mootll ❑ Other Number of living units: :-1---. Number of bedrooms_- Number o baths __- -Lot size ___ ______ _ _ ______ __________ Water Supply: Public system ❑ Community system ❑ Private �epth t ater Table _______ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam 0 Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pint sewer is available within 200 feet. Septic ank: Distance from nearest well 'Z}b� _0__Dista c�J fro fen�d�'n___j__0-_._---Mater i__ _ No. of --;x------ � - ?Liquid depth--- ----- _----__ Capacity Size____ __ _._ f Ca acit Dispos Field: Distance from nearest w 1 + _49 ___. Distance from foundation _ (.__.Distance to nearest to li z ___ Al Number of lines_________ _� ___- _Length of each Iine_________ _ _ ___ Width of trench___.__ T e of filter materia rr- g yp _-- ' -- -- - epth of filter material---____-- --�___---Total len th -�- --------------------. Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot-line_________________ [] Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h---------------------------__---- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------- .._____- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------______________________._------------------Distance from nearest building__---------------------------------------- -Distance ______-------- __-____-_---_________- _ Distance to nearest lat line_-_•----------------- ---------- ------------------------------------------------------------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- 4 -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- -----------------------------------------------•--------------------------- ------------------- --- -- --- I her ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc;s, 5ta laws, and rules and regulations of the San Joaquin Local Health District. w E --- ------------------------ -------------------------------------------------------------------------(Owner and/or Contractor) 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 DAT ---------------------- REVIEWEDBY--------- ------------- ----- ----- --------------------`_---- --------------------------------------------------- DATES--- ---------------------I-------- ------------------------------ BUILDING PERMIT ISSUED________________ _ Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- _____________________________________________________________________________________________________________________________________________________________________________________________________________________________ F __________________________________________________________________________________________________________.________________________________--__________-______________________________I_-__j_____-___-___-__--__-________________ FINAL INSPECTION BY: X ------------ Date r_1- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amoriean Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M 8-51 Revised W-2100