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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 he work herein described. This application is made' in compliance with County Ordinance No. 549. 0(00 —11 JOB ADDRESS AND LOQATIO - -- ------------ ---------- Owner's Name----------- I ------------ ------- -- ------ --- -------- ------------------------------------------------ Phone----------------- ---------------I ------------------------------------------------------------------- Address------------------- Contractor's Name----------------------- - -------------------------------- --- ��; --------------------------------------- Phone---------------------------------- Installation will serve: Residence Apartment He e E] Commercial ❑ Trailer Court E] Motel ❑ Other E] E Number of living units: ---1--_ umber of bedrooms Number of baths Lot size --------- ----------------------- Water Supply: Public system E] Community system ❑ Rtiva fe Depth to Water Table -- ----=ft. Character of soil to a depth of 3 feet: Sa' nd E]. Gravel E] Sandy Loam [] Clay Loam Clay ❑ Adobe Ej Hardpan [E] Previous Application Made: Yes 0 Nog New Construction: Yes)� No [] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool perm-Iffed if publicsweV's-a-v`ail/able within 200 feet.) fro --------- Sept' Tank- Distance from nearest well--- Distanc f Otion----/10 Materi, I ---- No. of compartments"______"""""" �5ize-_ C ___-Llq,id depth-____"-"""-- ------------Capacity-904 Disposal Field: Distance from nearest well----- Distance from foundation-----10--------Distance to nearest lot lelNumber of lines-------------9- -------- Length of each line------ 1 #2 ------- ------ *------Width of trench-------10--------------------- Type of filter maferial--15-t-k��- Depth of filter material-___---Iff---------Total length-----_- r ------ - t D ram 6� See age Pit: Distance to nearest well-----il-- ---- a ,on-----3-0--------Distqpp to nearest lot iny -------- Number of pits--------A----------Lining ma"tEr7a"19 ...... ---------r-----------IS e: Djamefer---------;-----------Depth-------- in ---------- Cesspool: Distance from nearest wel-----------------Distance from foundation- ------------------Lining material---__-----__--___------_._--------- Size: Diameter---------------------------------------Der�f q ------------- ---------------------------------------Li uid Capa4��fy --- ----gals. - -----------—------ Privy: Distance from nearest well- -___-" _--___-----__-- --------------Distance from nearest building-" ❑ uilding--El Distance to nearest ]of line ^ F--------------------------------------------------------------$t RemodeAq 'a md/or Irepa i ring (describe}:-_F- -- ---------- ------- --- --- ------------------------m------------------------------------- ---------- --------- ------------ ------ --- ------ -------- - ------------•-----•---------••--------------- ---------------------------------------------------- ----------------------------"-------------- ------------•---U - --- ------ ------------------------------------------------------------------------ ------------------------------------------------------I------I----------------- ----------------------------------------------------------I----------------------------------------------1-1---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count, ordinances, State laws, anjd rules and r guafionsil6f the San Joaquin Local Health District. (Signed)--------- ------------------------------------------------------------------(Owner and/or Contracto-O' By:----------------------- --------------------------------------------------------------------------------(Title)------------------------------------------------------------ -iocation of,system in relation to wells, buildings, etc., can be placed on reverse side). (Plot plan. showing size 0 .. FOR DEPARTMENT USE ONLY N APPLICATION ACCEPTED ' DATE -PBY------s:--:!=�N- REVIEWED T - rB�--------- --------------------------- ---------------------------------------------------- -------------------------------------------------- DATE----- ' BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations----------------- ------------------------------------------------------------------------------------------------------------------ -------I----------------------------------------------------------------------------------------------------------------------------I-------------------------------------------------I----------------------------------- ------------------- --------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- -------------------- -------------- I------------------------- -------------------------------------------------------------- ------------ --------------------------------------------------—,---------------------------------------I------------------------ ---------------------------------------------------------------- ------ FINAL 'INSPECTION BY:----------------/�a ----- Date------ 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 ES-11-2M 8-51 Revised W-2100