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APPLICATION FOR SANITATION PERMIT Permit No. __.........._ - .... (Complete in Duplicate) 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 O dinance No. 549. d &7r2 gE. �' JOB ADDRESS AND LOCATIO �''1 - --------------------- -•-------------- Owner's Name---------- Phone Address .... '.. + ---- ---- -------_/_ ---------------------------------------------------------------------------------------------- Contractor's Name_0 --------------------------------------------------------------------------------------------------------------- Phone---------------------------•------- Installation will serve: 'Residence NApartment House ❑ Commercial E] Trailer Court E] Motel L] Other E]l pp ( Number of living units: _!._____ Number of bedrooms ._+ __- Number of baths [_le Lot size _jam____ __�_6---------------------________-___ Water-Supply: Public system ❑ Community system ❑ Private I§ Depth to Water Table- ft. Character of soil to a depth of 3 feet: Sand E] Gra vel E] Sandy Loam N' Clay Loam ElClay 1-1Adobe ElHardpan ❑ Previous Application .Made: Yes E] No M New Construction: Yes ;9 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 No se tec tank.or cess ool- ermiffed.lif p ublic sewer.is-.available..within-200_feet.) Septic Tank: Distance from nearest well__ __..� Dista n a fIr'orp foundation___.f f=_______-.Material-_--_-___"-____.__"_____________________________ I No. of compartments----,�-----------------Size-- '_" -_lJ -.---Liquid depth---------! ------------ -Capacity---f - --- F +r r Disposal Field: ? 'Distance from nearest weft---47 - Distance from foundation..,�9___--_._.Distance to nearest lot line.-%5 Number of lines__3___________ ___________ Length of e 1 ned� �_ Nif�th of trench___ _�_____._________-__ Type of filter materia_ _Depth of filter material--__. _. Total length___ b_ ------ --- Seepage' Pit: Distance to nearest we L________________'n_Distance from foundation--------------------Distance to nearest lot line----------------- 171 Number of pits----------------------Lining material-------- ------Size: Diameter-----------------------Depth-----------------•-------------- Cesspool: ----Cesspool: Distance 'from nearest well-________________Distance from foundation--------------------Lining material--------------------------------------- ElSize: Diameter--------------------------------------Depth--------------------------------------------- -----Liquid Capacity----------------------------gals. Privy: Distance from nearest well_..____________________________________ Distance from nearest building_.__"-"----__.__________________________- ❑ .. Distance-to nearest lot line-- ----- -------------------------------------------------------------- ------------------------- Remodeling and/or repairing (describe): °-------------------------------------------------------------------"-•------------------------------•------- ------------------- ------------------------------------------------------------------------------------•---•------•--------•--------------------------------------------------------------•--•- •------------------------ ------------------------------------------------------------------------------------------------------------------------ 1 A hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County or finances, State laws, and rules and regulations of the San Joaquin Local Health District. w (Signed)-------------------------'------• -•---- --•-------------------------------- ------------ ------------------------------------------------------------------------Owner and/or Contractor) '-------------- --------•--------- -- -----------------------------------------------------------------------------(Title)-f�---------------=--------------------------------------- (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 BYF '+ ------------------------------ -------_ --------------- ------------------------------------•--. DATE--- f� REVIEWEDBY----------------------------- ----------------------------------- ---------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------- ------------ ------------- ------------------------------------------------------------------ DATE---------------------------------------------- -------------- Alterations and/or recommendations:--------------------------------------------------------------------------................-------------_-----•--------_--------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- ----- - --------•----- ------------------------------------------------------------------------------------------------.-..--------------------------------- ------ FINAL INSPECTION.B ✓ ' -,_,4604------------------- 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