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�i APPLICATION FOR SANITATION PERMIT Permit No. }" (Complete in Duplicates / 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. JOB ADDRESS AND CATION.. -- .--.4(---j---------- C--------------------------------------------------------------------- --------------------- ------------- Owner's Name_. ----- --- ---------------------------------------------------- -------------------------------------------- Phone_-� __-.----------- Address.............•--- -•--------- - ------------•-----------------------------------------------------------------------------------------------------------------------------•--------- Contractor's Name............- .. ----------------------------------------------------------------------------------------------- Phone-----F-- -_ � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -2. Number of baths _-1---- Lot size __#�aA__,lG G------------------------ Water - - - -Water Supply: Public system Community system ❑ Private E] Depth to Water Tablp,,_3_47ft. Character of soil to a depfh of 3 �]ef: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Acl?§O�Hardpan [] Previous Application Made: Yes E] Previous New Construction: Yes ❑ N �� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic TTa`nk,:y C� Distance from nearest well___-----______Distance from foundation-------------------_Material__________________________________________-_____. �Fx j/ No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity------------•---------- Disposal Fi Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line-___-____________ '�"y❑f�� Number of lines-----------------------------------Length of each line--------------------------.__.Width of trench-------------------_--------------- I Type of filter material__________________ __ epth of filter material-----------------------Total length---_------------.-__-_____________________ i 1 Seepa Pit: Distance to nearest well _ ___ _____ ___Distance fr m fou ation_�'�'____..Distanc�to nearest lot line__________ Number of pits-------- ---------- ining rhaterial� Size: Diameter-----"'�----_.Depth----/�_f_;---------..-- esspool: 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 to nearest lot line-------------�-------------------------------------------------------------------------------------•__---------------------------------- Remodeling and/or repairing (describe):____----_y"` _"--------------------------------__.--------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------=-------------------------------------------------------------------------------------•--------------------- -------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Statealand es nd regulations of the San Joaquin Local Health District. (Signed)-------------- --------- -- ------------ - _----(Owner and/o ntr to - --- - - - - -- - ----- By:----------------------- •� a (Title) :M4t (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--------------------------------- -------- ------- --- ------------ DATE-- BUILDING PERMIT ISSUED------------- -------------------------------------------------------------------------------- DATE----- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------- ------------------------------------------------------n------�------------------------------------------------- ------------------------------------f------------------------.y----------------------------------------------- FINAL INSPECTION BY:------- � _----------------------------- Date L ` f --------------- r 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 8-51 Revised W-2100