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APPLICATION FOR SANITATION PERMIT Permit N _ 1 __ (Complete in Duplicate) Date Issued _______________________ 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 with County Ordinance No. 549. s/�ie - - --- I JOB ADDRESS AND LOCATION.. CP5 - - (�"2"• lv-/ Owner's Name--------- -------X ------------------------------------------------------------ Phone------------------------------ Address---------�� _ 4� �4---Al-/----------------e0-- - -------------------------------------------------- ------------------------•------- Contractor's Name-- --------------------------------------------------------------------------------- Phone----------- -I p� $ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [} � Number of living units: -3.:- Number of bedrooms __ _ Number of baths ___3-- Lot size ___J ------ _______________ Water Supply: Public system ❑ . Community.system ❑ Private 04 Depth to Water Table _ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [❑ 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 weil___3__0___Distance from foundation°___- _�}--_=___.Material-__ __________- ❑ No. of compartments------------_2—--------Size____ �f _S Liquid depth------�---_-.__.____Capacity---Ao�(_O-___ i Disposal Field: Dis-i•ance from nearest well-----:� U___-_.Distance from foundation_______(l?------.Distance to nearest lot line __---__ ❑ Number of lines------------ - Length of each line-_,4_�----___�--------Width of trench_____ _ _____1___________ Type of filter material a ___Depth of;filter material---J4----_-------Total length_____36PQ_________________________ Seepage Pit: Distance to nearest well_____________________Distance-from foundation--------------------Distance to nearest lot line_--_____,_______ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------------------,--Depth--------------------------------- Cesspopl: Distance from nearest well-----------------Distance from foundation-------------------Lining material-----_------____________________-___. * ❑ Size: Diameter------- ------------------------------Depth--------------------- -----------------------------Liquid Capacity---------------------------- gals. `V)� Privy: Distance from nearest well------ ------------------------------------------Distance from nearest building----------------------------------------- El _ ___❑ Distance to nearest lot line --------------------------------------------------------------------------------------------------------------------------------- 1 Remodelingand/or repairing (describe)----------------------------------------------------------- ---•---------------------------------------------------------------------- ---------------- -------------------------------------------------------------------------------------------------------------------------•- ---------------------------I------------------------•-------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s, d rules d regulations of t S Joaquin Local Health District. (Signed]. ---- ----- . . (Owner nd/or Contractor) ----- ---------------------- ------------- - By:--------------•----------------------------------------•---------------------------------------------------------------------------(Title)---------------------------------------------------------------- F (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------------ _ DATE-- = ---------------------------------- REVIEWED BY----------- - --------------------------------------------I--------------------------------------------- DATE---------- ------ /� ---------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------- ------------------- Alterationsand/or recommendations----------------------•------------------------- --------------------------------------------------------------------------------------------------------------- -------------------------------•---- --------------------------------•-----------------------------------------------------------------------•------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------•--------1_______,__--------- ---------------------------•------------------ ------------------------- --------------- ---------------------- ---------------------- ------------------------------------------------------------- ` ------------------------ 5�1 QateFINAL INSPECTION BY: � . Q/ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21v1 5.51 Revised W-2100 .