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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 Countyrdinance No. 549. JOB ADDRESS & LOCAT N__�._ - -____ ----------------------------------------------------------------- ---- --------- Owner's Name..----------`•'-`-t"'-�---- ----`•---- - f� ----- ------------------------------- Phone- C- I Address....... } '" Contractor's Name 1�------- ----------------------------------------------------------------------------------•--------------- Phone----------------------------------- installation will serve: Residence [V/Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofe� /JOtthf r E]-__ Number of,kving units: _/(Community Number of bedrooms -___ Number of baths J---- Lot size __-sEA--____._�!4 _________________-_____ Water Supply: Public system,. system ❑ Private ElDepth to Water Table ________ ff. r Character of soil to a depth of 3 fee+: Sand Gravel F] Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ❑ No EW Construction: Yes R/No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if, ublic sewer is available within 200 feet.)/J��,1 Septic ank: Distance from nearest well I tan;elfrom foun t�ion____�'`C_____.Materi I _ - - No. of compartments------ ----------Size_- _--� - .Liquid de t __________ � p y-- I � _ gyp► Ca acit ___Q_� __. DispI Field: Distance from nearest well�VI1" Distance from foundation _, __Distance to nearest lot liner-- ,[� Number of lines_________ _, ,t______ _ :Length of each line-------_______1 -ot.....Width of trench_____ Type of filter materi __' ( epth of filter material______!-----:---Total length---------hnr__o______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Ej Number of pits----------------------Lining material---------------r-------Size: Diameter-----------------------Depth---------------------------------- Cesspool- Distance from nearest well-----------------Distance from foundation------------------..Lining material-------------.-----------------._.____- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. t Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line--------- --------------------------------------•---------------------- R - Remodeling and/or repairing {describe):------------------------------- ---------------------------------------------------•-------------------------------------•------------ - -------------------------------------•---...------------------------------------------------------------------•---------------------------------------••---------------------------------------------------------------------- fi ---------------------------------------------------------•--------------------------------------------------------------------------...-------------------------------------•-------------------•-------------•----------- ,. ----------------------••-------------------------------------------------------•-••----------•---------------------------------------------------------------------------------------------I--------------------------------•- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State iws;/and rules and regula+ions of the San Joaquin Local Health District. Si ned 9 )... - s _ ------------------------- ---- ------------•--------------------)Owner and/or Contractor) I BY: -•------�------° Title )--------------•------------------------------------------------ (Plot plan, showi6_/ize 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--------- - BUILDING PERMIT ISSUED---- -------------------------------------- DATE----------- Alterations and/or recommendations----------------•-----------------------------------------------•----•----------------•-----•-•-----------•----------------------- j� FINAL INSPECTION BY--------- Pig-- a Date -�4/ ------------------------------- SAN JOAOIJIN 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-2100