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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) S . Date Issued ____��__�____� Appiica*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 N"qq. 549. A!` JOB ADDRESS AND LOCATION 3.�� --- G1� 'h1i4 Tom... lJ Owner's Name C.�_ '............................. /L/L{5 6 ------------- - Phone Address------- ---------------- �� g 1� ------------. -------------------------• ---•---•-------------------- ---- -- j ------- Contractor's Name hT_.!�-- ------•--�----��---------------•------------------• ------- Phone. - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___--- Number of bedrooms ..------ Number of baths -------- Lot size -----------___________________________----.-______-___.__-- i Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. i Character of soil to a'depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan E] Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ \ 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 foundation----___-____._.___.Material------------------------------------------------ - No. of compartments +- ---Size__ _--------------------------Liquid depth. Capacity Disposal Field: Distance from nearest well-_-` .,Distance from foundation------ d-!_...Distance to nearest lot line--------- ,11 Number o7 lines-----------c---------------------Length of ea.ch•line------ --7-3----.-------Width of trench--------�- � --------------- Type of filter material_;-..----_Depth of filter material-------- ----Total length----------------7_�s_________________ Seepage Pit: __Distance to nearest well______________________Distance from foundation___________=..'_ Distance to nearest lot line----------------- r `V;?l 4,��R!umber of pits--------------- ------Lining material---------------------- Size: Diameter.------- --------------Dept{n--------------------------------- Vr Cessspool: Distance from nearest well----------------Distance from foundation.....................Lining material---.-----------------_-____.__--_____. ❑ Size. Diameter------- ------------------------------Depth---------------------------------------------------Liquid Capacity-_----------------------•_gals, Privy: Distance from nearest well_________________ _-------_----------------------Distance from nearest building----------.__.._______._____--i----_.____. ❑ " Distance to nearest lot line------- --- ----------------------- - ---------•---------------------------------------------------•------------------------------=---------- \N Remodeling and/or repairing [describe ------- -------- 4 ;"'_'�`-er< -----------------=-- --------- ----------------•--=-----------------------• -----•- --- -- -- - --------------•----------------------------------------•------- ----------- -•---- 0 ---------------- -=------- ------- ----------------------=---- • ---- - 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)- -- ---------I ---------- - - ------ -- - ---------------------------------------------------------------------------------------(Owner and/or Contractor) BY� . -----------------------------------------------------------------(Title)----------------- ------------------------- ------------------ (Plot pl ,.showing sizt, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- --- - --•-------------------- DATE------------ ---- --- �.� REVIEWEDBY-------------------------------------------- - DATE------------------ •---- -------------- --------- ---- BUILDING PERMIT ISSUED--------------------------------- DATE... Alterationsand/or recommendations:----- --- ------------ ---------- --------------------------------------------------•-•-----------•--------------------------••------------------------------ ------------------I------------------------ --------------•-•--------•----------•------------------------ ---------------------------------- ---------------------------- -------------------------------- -- -:--------------•------••--------------------------------------•---•------- ---------- -------------------------------------------•------------• --- ------------ ---------------- -----------•--------------------- ----------------------------.....---------------------------------------------------- ---------------------------- -------- •--- FINALINSPECTION 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-9-21A 145446 ATWO9" �2-54