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APPLICATION FOR SANITATION PERMIT Permit No. _S............... {Complete in Duplicate} . y Date Issued . 'S Applica;ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compliance with County Ordinance No. 549. JOB ADDRESS ANU LOCATI7 `r �--- - - Owner's Name = -�-- - ------------------------------------ --------------------------:----- Address--------------� -- ---------.-------- - -- --- ' .. - ---- ----- Contractor's Name___________________ Installation will serve: Residence ®/partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number'of bedrooms _ - Number of baths ---/-- Lot size ---Q _.fh_1V-Q---___.________________ Water'Supply: -Public system ❑., Community system'❑ Private 2-1&pth to Water Table __yd ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 3---Hardpan ❑ Previous Application Made: Yes ❑ No New Construction- Yes No 0' TYPE,OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitFed if public sewer is avails !e within 200 feet.} ......-. , 4... , / � � a Septic Tank: Distance from nearest well �Q --:Dista cer,from� oundation____!�_�,________-Mater-sal_________________________ ,, r EK No. of compartments--------�------------Size _ .:_�-_yf��__�A,7.Liquid depth---- --------------Capacity _..,��0 Disposal Field: Distaste from nearest well,__C0_�_.. ._Distance from foundation_____[OQ___-__Distance to nearest lot line________ Number of lines______------_../._____ __ Length of each line_____3-0 11 -iii-------.Width of trench---�_�--------------------- r f h gType or filter materiai,� ux ___ ______Depth of filter materiaL___.1_ ____,___ _Total length Seep Pit: Distance to nearest well_____ -------Distanc� -_.- fCrsora,foundation____,/..............Dista�ce to nearest lot line------------------ Number of pi /- ts------ ------------Lining material-.O --- __t_- Size: Diameter.... _-si cv..--------.Depth_.-_x*S------------------- 6 Cesspool: Distance from nearest well-________________Distance from foundation--------------------Lining material__- ------------------------------------------- ❑ Size: Diameter------- -------- ---------------------Depth---- ------------4----------------I-- ---------------Liquid Capacity----------------------------gals. S Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ El _ ---.._______________--_--------------.❑ Distance to nearest lot line -----=-----= r--------------------- ------------ ----`-------------------------------------- -- Remodeling and/or repairing (describe):-- ---------- --------------------------------------•--•-------------------------------------•--------•----- ' . o - {-------- ----------- ----------------------------------------- -------- , --------------------•----•----------------------------------------------•--------------------------------------------------------------------------------------------------------------- Ihereby..certify t------------------ Q 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 regula+ions of the San Joaquin Local Health District. 1 ----------- � ------------ ------------ - •- --------------------------{-T--i-+--l-e-}----• -----------,C iand/or ned}---By--------------- ----------------------------------------------•---------------------------------- {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-------- ' REVIEWEDBY----- --------------------------------------------------- --------------------------------------•---------------------------- DATE-- BUILDINGPERMIT ISSUED-------------------------- --------------------------------------- ----------------------------------- DATE.----- -------------•-------- Alterations and/or.recommendations-------------------------------------------------------------------------_-•----------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- ----------I----------------------- ----------------------- --------------------------------------------------------------- -----------------------------------------------------------------•-------------------- ------- V� ----- -------------------••------------------------------ --- ----- ------------------------ ------------------------- FINAL-INSPECTION BY..` - ---------•----- Date----------6---- . 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