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t�ly APPLICATION FOR SANITATION PERMIT Permit Nq'�`7p__ (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 with County Ordinance No. 549. I JOB ADDRESS AND LOCATION..._ Owner's Name--- / - -------------•---••- -_----------------------------------------------------------- Phone----•---------------..._..---------- ------------- Contractor's Name----- -- - -- ------ - ---- --------------------------- ------------••------------ • _--------------- Phone///' '"d�• {- Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----/-- Number of bedrooms ___2.- Number of baths .-I___- Lot size -------X._J__r,1.___--------------------- Water-Supply: Water-Supply: Public system *00tommunity system ❑ Private I] Depth to Water Table , ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 40<ardpan ❑ Previous Application Made: Yes ❑ ; No44—New Construction: Yes I] No TYPE OF INSTALLATION AND SPECIFICATIONS: I % (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well:______________Distance from foundation--------------------Material ______________________________________________- e No. of compartments---------- :-------------Size-----------------------•--------Liquid depth-------------------------Capacity----------------------- `V Disposal Field: r Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line------------------ Nu mber _____---___:.__.Number of lines1-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material_________________________Depth of filter material-----------------------Total length___.___________.____________ ------------ Seepage Pit: Distance to nearest well-----t- 4________Distance om fou da i n......-.211 ..Distance to nearest lot line____ Number of pits-.!---/--------------Lining material Siz Diameter-_ Depth,21.10_�____________--____ Cesspool: Distance fiom nearest well-----------------Alston e from fo ation--------------------Lining material------ ------------------------------- ❑ Size: Diameter----=------------=--------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well __________-------------------_-----------------Distance from nearest building_,________________-_________.__..___._. ❑ Distance-ta nearest;lot,line:------- ------------- ------------------------------------------------•---------------------------------------------------------------------- r . . 4 Remodeling and/or repairing (describe):--------------------------=---------------------------------------.---------------------------- ----------------------------------------------•-- - ----------------------•------•-------------------•-----------------------•------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------t t + 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)-•--• -- ---- -- �_ r Contractor) By: ._'._ .. --- ------ ---------------- ------------------------------------------------- (Title)--- �"" � ------------------ (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). < f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------- - r DATE------------- =~ 1 �5- DATE REVIEWED $Y ------------------------------- -- ------ --------------------------------------------- BUILDING PERMIT ISSUED---------------=------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:------------------------------------------------------------------------------------------------•-----•----•-------------------•-- I ------ FINAL -INSPECTION BY:----" - Date ,l f/ z� y 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