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APPLICATION FOR SANITATION PERMIT Permit No. _ ________ .......... (Complete in Duplicate) )kN Date Issued ---- 5 _,. Appliation 1s ere y ma e 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. 4 JOB ADDRESS AND LOCATION--------------- Q------`S� t4--------- ,/ I _C, Ems- -Y------------------ ------------------- Owner's Name '----•-----1 1_1�.� -------------------------_---=------------------------------------------------------- Phone------ ,�--�- Address--------------------------------------------------- `1 Contractor's Name------------------ -------------------------------------------------- --------------------------------------'----------------------- Phone--------_-------------------- Installation ------- •----Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � 1 Number of living units: ____L Number of bedrooms ---*2___ Number of baths ---L Lot size s?)( _�Z'0__________________________-_-_-__ i Water Supply: Public system,. Community system '❑ Private ❑ Depth to Water Table -------- ft. ,—-Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe `l Hardpan '❑ 1 Previous Application Made: Yes ❑ No ' New Construction: Yes No F-1Al �` F 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-----1O---------Material--,ZIA., .•_________________________ No. of compartments________-__�-- ___Size_____3XJ ------Liquid depth____------- -_______Capacity Disposal Field: Distance from nearest well___ _f ----Distance from foundation------/_D__ _Distance to nearest lot line___ -�� _ K Number of lines_________ ____�'3-____ ____Length of each line___-___________--_________-_.Width of trench--------- Type of filter material.---.- --Depth of filter material____-� ��.--------Total length-__-----------f_dQ_-_____________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line__-___-__________ t ❑ Number of pits---_------------------Lining material----------------------.Size: Diameter----------------.-------Depth---______----------_________ 1 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) ---------------------------------------------------------- ---------•---------------•------------------......... ---------------------------------------------------------------------••--------------------------------------------------------------------------------------=---------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------=----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------- 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. i (Signed)------i �`� ----- --- ;c°-- ---- - ------- - ---- ------------- -----(Owner and/or Contractor) BY: - ----------------------------------------------------------------------------------(Title) --- - ------------------------------------------------- (Plot plan, s ing 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 D` f � ---- J ---------------------- BUILDING PERMIT ISSUED---------------- ------------------------------------------------------------------------------.-- DATE-- - - 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 8-51 Revised W-2109'