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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 descriw. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND,�CATI.ONYoLe-�_ ------- Owner's Name-------6� 19,2121,1? 7 Phone--------- ------------------------- Address----- _4-x I -------------------------------------------------------------------------------------- Contractor's Name-------•-----•--------------------•------• --- --------- ------------------------------------------------------------------------------- Phone Installation will serve: Residence)6 Apartment Ho 0 Commercial E] Trailer Court Ej Motel 0 Other ❑ Number of living units: --- Number of bedrooms ___Nof baths ---J__ Lot size ---1_e_ Water Supply: Public system ❑ Community system El Private KDepth to Water Table __3tft. Character of soil to a depth of 3 feet: Sand El Gravel [] Sandy Loam E] Clay Loam El Clay El Adobe Hardpan E] Previous Application Made: Yes El No XL New Construction: Yes g No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publi�wer is available within 200 feet.) Septic Tank: Distance from nearest well---- ----Distanc fromyoundj��,____/o---------Mat i,a I-----C4_nld_t - No. of compartments__------ --Size----. ----Liquid depth-____-- --- - _X,_�---Lqu Capacity_- 5� Dis I Field: Distance from nearest well ----Distance from foundation----- Distance---f_o____nearest lot fin _500 Number of iines-------------/-- ------ - Length of each line-------LA-10-------- Width of french-...'9_4 Type of filter ma, epth of filter material------ ------Total length------- Seepage Pit: Distance to nearest well------ ---------------Distance from foundation--------------------Distance to nearest lot linir�_ EI Number of pits----------------------Lining material----------------------.Size: Diameter------------------ Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation----r--------------Lining material___________________._ ------ El Size: Diameter------- -------------------- ---------Depth------------------------------------------- -- -----Liquid Capacity--- -----------------------gals. Privy:I Distance from nearest well-----------------___--_____-_--._._-_____-__Distance from nearest buildin E g------------------------------------------ Distance to nearest lot line-------- Remodeling7 andZcj pairing --- ----------- ------- ---- r �5� .., . ... ....... ----------------------------------------------- --- --- - ---------------- ------------------------------------------------ ------------------------11--------------------------- --------------------------------------- ........ ---- - ----------------------------------------------------------------------------------------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St7a -' laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_-f------- ---- ---- ------------------------------------- -------------------------------------------------------------------(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 APPLICATION ACCEPTED BY------------------------------------------------------------------------------------------------- DATE--------------- REVIEWED BY----------------------------- ------------------- BUILDING PERMIT ISSUED-------------------- ----------------------------------w----- --------------- DATE-------3- --------------------- -------------------- DATE------- --------------------------- -_ ------ -- Alterations and/or recommendation --------------------------- ------�P_ -----------------------------------------------I------------------ ------------------------------------------------------------------I--------------------------------------- ------------------------------------------ -------------------------- -------------------------------------------I----------------------------I- ------------------------------------------------- -----------------------------------------:------------------------ -------------------------------------------------------------------------1-1---------------- ------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- -------------------------- ----- .... . ---- --- ---------.---.-.-. f - FINAL INSPECTION BY:------------ 4— - ---- -------------------------D--a--f---------------- ---------4--c---------------------------� - ------------I------- ------------------- ---- 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 E5-9-2M X0_52 Revised W-2100