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APPLICATION FOR SANITATION PERMIT Permit No. ._• _ __.. (Complete in Duplicate) / Date Issued ______ Applica+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 rOrdinance ,No . 549. JOB ADDRESS AND LOCATION I' �V- 1 .......P_Q,3- -------------•-------------------- Owner's Name ` - -- ------------ -- - --- Phone-----•------------ Address---------------..................................-----------------------------------------•-----..........----------------------------------------------- ----------------------------------------------------- Contractor's Name..---- ------------- '-----------------------------------------------------------------------•------ Phone--------------------------------- Installation will serve: Residence ar ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '_____ Number of bedrooms/_____- Number of baths _1_._.. Lot size ----------------------- Water _______________Water Supply: Public system mmunity system ❑ Private ❑ Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ay Loam ❑ Clay E] Adobe L] Hardpan 0� Previous Application Made: Yes ❑ No New Construction: Yes N-11-011 TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or cesspool permitted if public sewer is available within 200 feet.) __ II i Septic Tank: Distance from nearest well___N `0istance fr found ion--- 1„�_____.__.Material__�_.. e_____ ------------ No. of compartments____----_ ,, 1 __.__Size_. _ } _ Liquid depth__________ ___________Capacity____ Disposal Field: Distance from nearest welllt!'..�_.M_istance from foundation-- ___-.Dis ante to nearest lot line. _ _ ___ 1 Number of lines--- --- --Length of each line------�6-__-- _ __.Width of french-------_----��-------------- Type of filter material ----Depth of filter material ------Total length---------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-______-__ ElNumber of pits----------------------Lining material-._------------_--_----Size: Diameter-------------- - ----Depth-_--------------------------_---. Cesspool: Distance from nearest well-----------------Distance from foundation.,_,_._._.-:__Y_,.Lining materialw__________________________--------- Liquid _ ____. Size: Diameter. 6— n De th----- __ -__ .-Li uid Capacity-:--t-_.--------------- afs. - p — = cl - - --9 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. Si ned _')�--------------- ________________ Owner and/or Contractor By:------------------------------------------------------------------------------------------------------------------------------ -----(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------------- ------------ ------------------ ---------- DATE-----------Z r.- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------- ---------------------------------- DATE-----------------------------------------------------------_ Alterations -------------------------•- - - ---------------------------- Alterations and/or recommendations:-•------------------------------------------- ------------------------------------------------•------- - ••----•-------------•------------------------------------------------------------------------------------------------------------------ ------------------------------•----•----------------------•------. ----------- 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