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APPLICATION FOR SANITATION PERMIT Permit No,�5-. --.-.- (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 Orc,inanc$e ;. 549. , JOB ADDRESS AND L CAT�ON__�_ ._-^ ----b'-Y-----------------•............. ------------- / Owner's Name _ --------------C1----------------- ------ ----------- Phone_ _ _ _ . - --- -•-- - --- - ---------------------------------I------------------------------------------ Address__ .. ' -- ----- ----- Contractor's Name-.--- --------- Phone--------.•------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Others❑ Number of living units- __I__. Number of bedrooms -1----- Number of baths_ Ot size ---lJ---x- ------------------------ Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table ________ ft. II Character of soil to a depth of 3 feet: Sand PP Gravel El ' Sandy Loam Clay Loam [I Clay C] Adobe Hardpan C]/ Previous Application Made: Yes [I No [R/ New Construction: Yes [rNo El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Septic Tank: Distance from nearest well------_----------Distance from foundation--------------------Material______._---.___.__.___...___--_._-___._.______._. ❑ No. of compartments------------------- ----------------------Liquid ---Capacity ----- -------Size--•------•-------- Liid dthp Y----------------- � I Disposal Field: Distance from nearest well________________Distance from foundation---------------------Distance to nearest lot line_______._______. r.. ❑ Number o'i lines---------------------- ------------Length of each line------------- -------------Width of trench---------------------------------- W Type of filter 'material-------------------------Depth of filter material---------------------*Total length------------------------------------------ /j { Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____.___________ t ❑ Number of pits--.-------------------Lining material-----------------------S;ze: Diameter----------------- Depth--- ---- --------------------- M Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ;maferia ---_______.____.__--_______________ ri ❑ Size: Diameter-----------------------------� -----------------------------Lq icl Ca city----------/-------- gals. I � p I Privy: Distance from nearest well-.._. / D Distance from newest bu ing___-__-.__ __ Distance to nearest lot line-----l- 0--------------------------------- ----------------------------a---------- -----------------------------•----------------------- ' -------- ---• Remodeling and/or repairing (describe):_________________ ----------------------------------------------------------------------- ----------------------------------------------- �------ - k -------------------- --- --- -------- --------------- -------------/-------- ----••--------------------------------------------------- I hereby certify that I have prepared this application and that the wo k�will befdone in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)... �' ----- ---- ---- ------ ---- -------- - ------------------------------------(Owner and/or Contractor) -- BY:------ -�_r .$.. °�------� - ---- --------- - (Title)---------------------------------------I------------------------ {Plot plan, showing size of lot, location of system in 61ai?on to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -_ DATE---W---------------------------------------------------- APPLICATIONACCEPTED BY�-•----- ------------ -------------- ----------------------------------------------- - QATE---��---- REVIEWED BY--------------------------------- R� --------------------------------•------- ---- --- ------------------------------------------------------------------------------ BUILDING PERMIT ISSUED--------- •---------------------------------------- DATE ----------------------------------- ------------ ` Alterations and/or yecommendations:__.--------------------------------- 8 1 -- - --------- --- C ----- -- 4 ------------------------------ -------------------- / --------•-------•----r.* FINAL ------------- --------- Date --- -------------------- f { 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 10-52 Revised W-2100