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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 1 Date Issued k 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. l JOB ADDRESS AND LOC ION----------- _ ��-> - / ------------------------------------- Owner's Name----_--------------- - ------------------ --------------------------- Phone Phone----------------------------------- _ Address__. -------------•-------------------------------------------------------------------------------------------------- --------------------------------- G Contractor's Name ----------------•---- I------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Uq—A-p-artment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other q❑ i- Number of living units: _ _____ Number of bedrooms --- --- Number of baths..--/---- _ -Lot size __--_ _ __r1w__C!___------___-_-____.__ Water Supply: Public system ❑ Community system ❑ Private epth to Water Table _ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g;._4-1ardpan ❑ Previous Application Made: Yes ❑ No"IR, New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is'available within 200 feet.) Se tic Tank: Distance from nearest well_��__. istance from foundation _Q_ _ _.M erial--_-_--- -+ _-W__ ------- No. of compartments--------Z- �ze--- `'K_5 _ Liquid de tn------- ----------------Capacity-.-- i�-,-- - - - q Disposal Field: Distance from nearest well +__.Distance from foundafion--.-- _ ----_-Distance to nearest lot line-- --TIP Number of lines- ______�.r-----______ Length of each line----, _7 Width of trench-_.-/__--_-_- _______._ / `r Type of filter materials"T, =_4_.Depth of filter materml----I-_�_-________Total length-------_9 r Seepage Pit: Distance to nearest well---___._---- ---__Distance from foundation__.--.________--- Distance to nearest lot lin __________----_ r ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- 41 Cesspool: 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) - ---------------------------------------•----•--------------------------------------------- ------------••----------------•--------------------• -------------------------•---------------------------------------------------------------------•------------------------------------------------------------------------ -------------------------------------------------------------------------- A I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County, ordinances, State ws, nd ruled regulations of the San Joaquin Local Health District. [Signed - [Owner and/or Contractor) 6 :- Title ---------------------------------------- ---------------------------------------------------------------- (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----•-------------------- 4 ----------- DATE---------- - REVIEWEDBY--------------------------------------------------------------------------------------------- ------------------------------- DATE BUILDING PERMIT ISSUED---------------------------------------------------------- --- -------------------------------------- DATE------------- Alterations and/or recommendations------- --- -- _-e-_-.-------------_-.---------------- ----------------------------------_- ------------------------ ------------------------------------------- _ _-- ---- ------------- __.__ -------------------------------------------------------------------------------------------- :r � .-- -- 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 8-51 Revised W-2100 4 o-