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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 Coin Ordinance No. 549. JOB ADDRESS AND CATION----} �RJ QQ . - -- ---- Owner's Name t--------- ------------------------------------ Phone._.----------------••-•- - -------------------- ---------- Address ... 5�-o-�------------••-_-_--- Contractor's Name........................... -- •. ---------------------------------------------------- ----------------------------------- Phone------------------------•---------- Installation will serve: Residtinc Apa ment House E] Commercial E] Trailer Court ❑ Motel ❑ Other Number of living units: F -__ umber of bedrooms •-�_ Number of baths ____/Lot size ___. ��(/�> Water Supply: Public system ❑ Community system K Private ❑ Depth to Water Table .Zft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ -No New Construction: Yes K No E]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_h4!6 Dist e fr m foundation-----1.6_.......Mate al------ - No. of compartments.__.__-.__ ' - _Size .I( ---e ______-_Liquid depth____ __________Capaci _ d¢ ---_ Dis I Field: Distance from nearest well--- from foundation-------Z_0----Distance to nearest lot line__fj.S.____. Number of lines___________ ____________ ______ Length of each line----------&_A0 -____-Width of trench__:._. Type of filter materiaL. S�k Depth of filter material______ f�-_Total length......-.... Q-------------------- Seepage Pit: Distance to nearest well_.__------------_-----Distance from foundation....................Distance to nearest lot line______-__________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------_---------------Depth__-____-__________-___-______ 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------------------------------------------ I] 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, Sta!rtas, and rules and re ulat the San Joaquin Local Health District. - (Signed)-•---- --=----!---- ---- j------- ---------------------- ------------------------------------------(Owner and/or Contractor) By:---------------------------------------------------------------------------------------- ---------------------------------------(Title)--------------------------------------------------------------- (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 APPLICATIONACCEPTED BY------•------------------------ --- ---- ----------- •---•--------------------------------- DATE----------------•----------------------- ------------------- REVIEWED BY---------------------------------------.......... -------- ------------------------------------------------- DATE------ -- ` BUILDING PERMIT ISSUED------------------ ----- ------_------ -------------------------•------------ DATE--------------_---- Alterations and/or recommendations:_-----------------------------------------___........................---------------------------•------------------------�---:•d 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 10-52 Revised W-2100