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APPLICATION---FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issuedd _ :`� , d)Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the /f/ork herein descri e f,This application is made in compliance with County Ordinance No. 549, 3 5 Z`-S .4-4 Cr 4/,Li'1t 4,e- �2)`• JOB ADDRESS A OC TION.-- - - - ----.-----�_ •A� ---- -- - - --��-- - - - - - - - '�--- ----- - - -�------A"`--,.; Owner's Name- t g - ------------ - ----- -------------------------- - Phone---------------------------------- Address------------- d• ^3 Contractor's Name------- -------- - -- -------------------------------------------- ------ ---------------------------------------------------- Phone----------------------------------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ 1 Number of living units: _-- -- Number of bedrooms --Number of baths __t-____ Lot size _----.-___________ --� -_ _ -.-.__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel K Sandy Loam$�, Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application. Made: Yes ❑ No $� New Construction: Yes j� No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , 1 (No septic tank 'or cesspool permitted if public sewer is available within 200 feet.) y} Septic Tank: Distance from nearest well_Ig- t-Distan from foundation--- ------------Material---- --. op No. of compartments--. Or. --�-_Liquid depth--------- - ---------Capacity___ Dis osaI Field: Distance from nearest weli-----/.`k�Distance from founclation.__1_�------Distance to nearest lot line W5_9 �,� X Number of lines-------- -------- gth of each line---- � ____ - Width of trench-_-. �f !N - -Len �-- ------------------- i Type of filter material__ Depth of filter material____-_--jr#4----.Total length----t aP------------------------- rl': Seepage Pit: Distance to nearest well-----_--------------Distance from foundation-------------------.Distance to nearest lot line--_-___---------_ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter_--------------------Deptn--------------------------------- Ir U Cesspool: Distance from nearest well-----------------Distance from foundation------------------.Lining material--------__- 1 Size: Diameter-------------------------- ----------------------------- ❑ ------ - Depth----- ------- -- ------Liquid .CapacitY---------------------------gals. Privy: Distance from nearest well-------------------- _-__---__----_-_-----Distance from nearest building ❑ Distance to nearest lot line------------------------------------------------------------------------ - ' Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------- ------ -- --- -------------------------------------------------------------- ----•----------------------------------------------------------------------------------------- ----------------------------------------------•----------------------------•------------------•-----------------------------------------------------•---•---•---------------------------------------------------------------- ordinances,---------------- ---------- -------------------------------------•------------------------------•--_-_-_-- _-.--------------------•---•----------•--------------- --------------•--------------- ------- - k I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County antes, State aws, a12;` rules and re ulations f the San Joaquin Local Health District. (Signed)---- ---------- --- - - -----' -------------------= ------------------------(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----------------------------------- ------------ ---------- - -- - --- ------------ DATE- --- -------- ------------- j - ----------------------- BUILDING PERMIT ISSUED------------------- ----------------- ---------------------------------- DATE-------- ---- --------------------------------- Alterations and/or recommendations---- ------- --------- ----------------------------------------------------------------•----------- ------------------------------• ------------------- -•-------------------------------------------------•---------- ------------ ----------------------------------------------------------------------------------------------•------------------------------------•---------- -------------------------------•-----------------------•-------•-----•------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ FINAL -----------------------------------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 10-52 Revised W-2100