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APPLICATION FOR. SANITATION PERMIT Permit No, 2-- if (Complete in Duplicate) Date Issued v�)_ Application is hereby made"fo 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. JOB AD SS AN A 0 ---- ------- Owne - - ------ ------------------------- Phone_ Address-- W-'4------ ---------- -------------- - -------------------------------------------------------------------------------------------------------- Contractor's Name_---------------------- .0 -------------------------- -------------------------------------------------------------- Phone Installation will serve: Residence rV1 WN Apar ent House E]• Commercial E] Trailer Court 0 Motel E] Other ❑ Number of living units': "Number of bedrooms _Number of baths __- ___-Lot size ------------------- 41- Water Supply: Public system El Community system E] Private Depth to Water Table - ft. 7----- Character of soil to a depfh,�of 3 feet: Sand [] Gravel E] Sandy Loam E] Clay Loam D Clay ❑ Adobee� Hardpan E] Previous Application 'Made: j 1:Yes E] No New Construction: Yes No Fj TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distancefrom nearest w,aI___4__0__')kstanc fro found Lj�ion---- f d -- ---------Mate lei------- No. of compartments-.-I'_------------.__Size_ Y _r_0k..).(.,4__L-iquid depth--------I. ....... K i� --------Capacity-_90-in-------- Disposal Field- Distanceffrom nearest well---- -moi--.._Distance from foundation_---1_0�......Distance to nearest lot line ----- Number 6' -1' fines _ ----------- Length of each line------ 40�--------Width of french__,.P__,.4 -- --------- Type of filter material___J-r_ -epth of filter material_---_ --Total length___.___ ------------------- Seepage Pit: Disfance4o nearest well----------------------Distance from foundation--------------------Disfance to nearest lot line---------------- F-1 Number of pits----------------------Lining material-----------------------Size: Diameter__.--------------.__Depth----------- Cesspool: Disfance,from nearest well-----------------Distance from foundation--------------------Lining rnateriaL----_-----_ ❑ Size: Diameter----. -------------------------------Depth--------- ------- --- --Liquid CajDa ify------------------ Privy- Distance from nearest well--------------------------------------------"----Distance from nearest building------------ ----------------------------- F-1 Disfance::,.fo nearestlot line_____---_ ----------------N----------------------------------------------------------------- rrep repairing (describe):____-___.___ -- - ------------ ---- ------- - ----- Remodeling and/or re, ---------------------_..........v...... ------------ ---------------------------------------------------------------•--------------------------------- -- t --------------------------•-----------------.------------------------------------------------------------------------------ --------------------------------------- -------------------------------------- Ii ------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rl.61as and regulations of the San Joaquin Local Health District. (Signed}---- �Rn�_ ----- ---- ---- ---------------- ---- 14OA4-—----------------------------------------- I----------------------------------------(Owner and/or Contractor) By:----------------- ---------------11--------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot,� location of system in relafion to wells, buildings, e+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 6Y. REVIEWEb BY---------- i� --- - ------------------------------- DATE---- ------------- ----------------------------------------- BUILDING PERMIT ISSUED--- ------------------------------ ----------------- -------I------••-------,DATE""- ------------------------------------------- --------------------------------------I------------- ---- -- -- -- ----_----------- DATE---------------- Alterations and/or recommendations:_.-----._____-:___._--------------------- i� ----------- ------------------------------------------------------------------------------ ------------------------------------------------------------------- ------------------------------------------------------------------------- --------------------------------------------------------------------- ------------- --------------------------------------- ------------------------------------------------------------------ ---------------------------- ----------------�:---------------------------- ------------ ------------- --- ---------------- ----------------------I------------------------------------ ---------------------------------- -------------- ----------------- -------------------- ---------------- ------ ---- --------- ----- --------------------------------------------------- ------------------------------------------------------------------------------ FINAL INSPECTION BY:---- Date------ ----------------- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street - Stockton, California II Lod!, Caftfornia Manteca, California Tracy, California ES-1-2M 10-52 Revised W-21001 1i