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APPLICATION FOR SANITATION PERMIT Pe rm1$ No. .. . .... (Complete in Duplicate) Date Issued Applica-1-ion is hereby made to the San Joaquin Local Health District for a permit to c nstruct and install the wor erein described. This application is made in compliance with County Ordinance No r49. JOB ADDRESS AND LO ON —------------------IVI-7----W----- ----------- Owner' Nam ----------- - ---- -- ------ ------------------------------------- Phone__.2_.;r--- -----e�� ?� Address_ - -------- Contractor's Name------------ , __ --h -- - --- ------------------------------------------------------------------ Phone___7_7/_--------- Installation will serve: Resi ence Apartment House Ej Commercial E] Trailer Court E] Motel [_1 Other E3 Number of living units: j---- Number of bedrooms ft4l- - Number of baths _,/--- Lot size -----(!5 Water Supply: Public systemx Community system E] Private E] -Depth to Water Tab] Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam E] Clay E] Ado>v Hardpan ❑ Previous Application Made: Yes Fj No)K New Construction. Yes W No F1 TYPE OF INSTALLATION AND SPECIFIATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 'LiA Septic Tank: Distance from nearest well. Distance from founclp,_/, ,,�7---------Maigrial......(7 No. of compartmerifs-2—------------------ .--_Liquid depth--j-'r.4,;------Capacity------ �� 7� Di ----Capacity------ Di I Field: Distance from nearest well.--j'--0`__Distance from foundation___/e... .....Distance to nearest lot line---_ _R J Number ine----- Number of lines---./---------------------t�-----Length of each line_______.3i�,* -----------Width of trench-------—e... .................. Type of filter material �_ ------Depth of filter mate ria ........Total length------ ------------------_-- Seve Pit: Distance to nearest Distance frr fo lation----/- ---- - -Distance to nearest lot line-_610------- Number of pits-_/----------------Lining material Size: Diameter------ ---- --- ----Dept k----- ---------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------.-_Lining material__--_-_________-______________-_--__. ❑ aterial------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity_ -------------------------gals., Privy: Distance from nearest well------------------------------------------------Distance from nearest building---------------- ------------------------- Distance to nearest lot line ------ --- Remodeling and,/ i!*_ — —— �9 ------------- --------------- --- -- --- Remodeling and// r repairing (describe).I,---�_ _ ------ C Ay_ ---------- ---- ------ -------------------------------- ----------- ------- ------------------------------------------ ----------------------------------------------------------------------------- - ------ -- - - -- --------- - o ------------------------------------------------------------- ---------------------------------------------------------- ---------------------- ------- •---------------- --------I---------------------------------------------------------------------------------------------- ---------------------*----------------------------------------- "red t I hereby certify that I , prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an le nd regulation of the San Joaquin Local Health District. i (Signed)--- - ------- ------%-----------L---- ------------------------------------------------------- _(Owner andki Contractor) B ------------ Y* ---------*---------------------------------------------------------------------------(Title)----- ---- ------------- ------------- - --- ------- (Plot plan, showing e of lot, location of system in relation to wells, buildings, etc., can be place on reverse side). �j e FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -------- -------------------------------- 5 ------ -----------_--- ------------------- DATE_.-------//- REVIEWED BY--------------------------------- �1LAC ----------------------------------------- ---------------- -------------- ------------------ DATE-------------------- ----------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommend a+ions:--------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------I------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_----------------------------------- ----------------------------------------------------------------------------------------------------------------------------- -------------------------------------------11------------------------------------------------- -------------------------------------------- ----------- ----------------- ---------------------- V --- -------------------------------------------------- ------------------------------------------------------------------- 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 Revised W-2100