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APPLICATION FOR SANITATION PERMIT Permit NO.1!/ (Complete in Duplicate) L �+ J Date Issued gplicaa•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. JOB ADDRESS AND LOCATION 71 - _ - -- - --- - -- ..r------- ----------------------------------- Owner's Name-------------------------- 1 _ - . -- - - -------------- ------------------- --------------- Phone------------------------------------ Address.-------------------------------------------------- --------------------------•-------- Address--------------------------------------------------•••-- Contractor's Name--------------- #4r -------------------------------------------------------------- -------------- Phone----••----------•----------------- Installation will serve: Residence Apartment House ❑ Com ercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units: __ ___ Number of bedrooms umber of baths _ -_-_ Lot size ____.__ �' -----------%__7 __ __'__._____ Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobeW Hardpan ❑ Previous Application Made: Yes ❑ No"25-- New Construction: Yes XNo ❑ 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 foun cion____ Material_-_. __Liquid dep.No, of compartments----___ .-- _------- Size____ -------------- Capacity Disq,osal Fie ld:**4'-'_Distarice from nearest well_-------Distance from foundation---60._ .. _Distance to nearest lot line___.__�� Number or lines___----_GIJ______Length of each line----- ep _�-__0- >Width of trench_-_______ fit-_-____-____ }ype of filter mate riah of filter material-----ly<<____._Total trench---------- 20 , 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------------------------------------- t ElSize: Diameter - ---------------------- - ----- Depth----- ---------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well----------_--------------------------------------Distance from nearest building_------------------- -_____--_-_.__-_._. ❑ Distance to nearest lot line-------------------------------------------- Remodeling and/or repairing (describe):----------------- ___ _ ..-•- ---. --------------------------------------------------------------.------------- --- ----- ------------------------------------------------ ------------------------------------------.------------•--•---------------------------•--------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------.------------------------------------------------------------------------------------------------------------- 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)-``j-- ------ - - ----------------------------------------------------------------------------{Owner and/or Contractor) By---- -------------------------------------------------- ---------------------(Title)--------------------•---- (Plot plan, s.)--owing, size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY----- ------------------------ -- -------------------------------------------- DATE------ 1 REVIEWEDBY------ ------------------- ----- --------------------- --------- ---------------------------------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:--"------------------ -------------------=------------------------•---•--------------------------•----------••--------------..-----------------•------------- A ------------------------- „ r -- i-y ---- - -----------.____-___ --_____--_z-.-_-_-_�Q__ _-_-_.--.-_- .___________---..__----- ---------------•---- - -- ------ ------ - - ------ ---- -- --------------------- 7.r--------------- --------------- - ------------ ----------------------- ------------------ - ----------•------------- -.------------- ------------------------------------------------------- --------------------- 7s 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, California Lodi, California Manteca, California Tracy, California ES-9-2M : Revised W-2100