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r APPLICATION FOR SANITATION PERMIT Permit No ---------- (Complete in Duplicate) Y 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 Ordinance No. 549. c JOB ADDRESS AND LOCATION---- ------- -------a- ---- - ------7 ------------ Owner's Name------01' ----- ---------- ---------� ------------ -------- ------ -------------- Phone----------------------------------- Address_.- �;;�;: .. ; Contractor's Name------------- ------r----- ti Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _l_____ Number of bedrooms _1___ Number of baths ___/_-- Lot size ---------- - Water Supply: Public system ❑ Community system Private epth to Water Table __/Oft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E] Hardpan ❑ Previous Application Made: Yes' No E] New Construction: Yes to ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan� Distance from nearest weli___.�?_--__Distance from found`ti --------)__ __.Mater'a�-___-___�-'"` [ No. of compartments-_-------Z�------Size------- - - i�_ _Liquid depth-------- ------------CapacitY-----_ --- C Disposal Field.-' Distance from nearest well------ Distance from foundation_____ ----Distance to nearest lot line__;_, ------- [' Number of lines________________ _____ Length of each line----------E'>_�i---T___-.Width of trench---------- ________-__ Type of filter material-_ } __l ____Depth of filter material_____ --------Total length------------EA t� _______________ Seepage Pit: Distance to nearest well____________________ _Distance from foundation--------------------Distance to nearest lot line____-_--___ ❑ Number of pits----------------------Lining material-----------------------Size. Diameter------------------------Dept h_-_.__________________--------- Cesspool: Distance from nearest well---------_-------Distance from foundation--------------------Lining material------------------------------------- El Size: Diameter--------------------------------------Depth------------- ---- ---------------------------------Liquid Capacity----------------------------gal ' Privy: Distance from nearest well-----._-------------------------------------------Distance from nearest building----------------------------------------- 171 Distance to nearest lot lire---------------------------------- ---------- ----------------------------------------------------------------------------------------------- • Remodeling and/or repairing (describe)---- ----- - ----------------------------------------- ---------- •------..---------------------------- -----------------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Staflaws, and rules and regulat'o s of the San Joaquin Local Health District. (Signed) ------.-----• (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). k FOR DEPARTMENT USE ONLY 4 APPLICATION ACCEPTED BY________________________ _____ ___ _'" --------------------------------------- DATE---------- , e�'- - -- REVIEWEDBY----------------------------------------------------------------------------------------------------------- ---------------- DATE-------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------- ------ DATE --------------------------------- Alterations and/or recommendations:-----------------------------------------------------------------------------------------------------------------------------------------•--------------------- ----------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------I-------- -----------------------------------------------------------------•-------------------------------------------------------------------------------------------- ----------------------•------------------------------------------------ ----------------•------------------------------------------------- ----------------------------------------------------- ---------------------------------------------------------------------------------------------- FINAL INSPECTION BY:- `------- --- - - ------ ---- - Date-----------J-- ---- ------ -------57-"fir----------- 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 8-51 Revised W-2100