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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 County Or finance No. 549. r�r JOB ADDRESS AND CATION. ---- - - ""_- - --Z_ -� --- -------------------••----------------- Owner's Name__ _- �--- ---------------------- Phone-------------_- ---- - - ------- ---- - --- -------- - ------ --- -- - � Address. ..... ----------------------------------------- -------- -••-- ---- --- -- Contractor's Name-_.----••-------- ------•----------------------------------------------------------•----------------------- ------•--- Phone----------------------------------- partment will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: -)----- Number of bedrooms -_umber of baths .___�__ Lot size __ _____ ____ __�___!;�* - -_ Water Supply: Public system ❑ Community system ❑ Private>< Depth to Water Tai ------ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W Hardpan ❑ Previous Application Made: Yes l] NoIS<` New Construction: Yes A No ❑ 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 (0__0---Disfance from foundation----1aQ.______-Mat' ,r'al---- No. of compartments------- —---------- -- _Q-Liquid depth-------- ----------------Capacity-1-I -_ Disposal Field: Distance from nearest well---/0--)-----Distance from foundation___IQ---------Distance to nearest lot line----4 Number of lines______________ _________.___ Length of each line______._ t6__ LS_QWidth of trench-_q_- Type of filter material___- 'irDepth of filter material-----/_9-_..___.___-Total length___---- f 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___________________________________ ❑ Size: Diameter. __— 'th - jiqui Capacity............ ------------ gals ._} Privy: Distance from nearest well-___ � _ _ _ __._ cfbe�fr 1R-� ` ❑ Distance to nearest lot line-----------------y�fJy ----- --+ --- - -- �{ -+ Remodeling and/or repairing (describe):___-____----------------- - - -- _e__ __ _--c_ _ 14 _ �•� `�r t!� V-14-4i ---------------- ----- -------------------------------••----------------------------------------------•-•-------------- ----------------------------------------------------------------------------------------------------------------------------- ------------------------ -------------------------------••---------------•---•-------------------------------------------------•---•----•------------ -------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County F ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----- —-----"T'------ (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------ --------- r REVIEWED BY------------------------------- ----------------------------- DATE-- t ~- BUILDING PERMIT ISSUED---------------------------------------- a_ -_--_--.;�*------------------ - DATE------ Alterations and/or recommendations:--------------------- •-_------- _ --_------------------------------------------ -----------•----------------- - .1-•------- ------------ ----------------------------------------- --------------------------------------- - --- - --------- --- - - ai- -;------------ -------------------------- � .------------------ ---- ------- ---- f FINAL INSPECTION BY----------- --------------- " ', Date--------- ----------M 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