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APPLICATION FOR SANITATION PERMIT Pe (Complete in Duplicate) c' ��^ Date Issued Application is hereby ma e 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 Ordinance No. 549. JOB ADDRESS AND LOCATIONAC r� -----�-2 - -- -------- - i ---------------------------------------------------------- Owner's Name = -------------- Phone---------------------------- If A-- -- 0 ----- -- AddressU---------- ---------- - ----- ------------ ----- -- ------ --------------------------------------------------------------- --- __ Phane Contractors Name---- -�---_ - -�.__�_-_-------�----- ----------- -- - - --- - ------�--�, -�---------- �--- �-- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0�ZT� Number of living units: -------- Number of bedrooms __,_____ Number of baths 1p___ Lot size ---- _I'_xl______1_S_ ---------______________ Water Supply: Public system ❑ ,Community system F1t Pr'ivate,[Ao-6epth to Water Table .........ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No W-�New Construction: Yes;❑ �No [g— ; TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) Septic Tank, Distance from nearest weld_________________Distance from foundation_____ -------------Material________-_---_ _--------------------_-_-_-_-_. ❑ . - No.,of compartments = Size Liquid depth Capacity Disposal Field: Distance from nearest well- -a-b_'--Distance from foundation____IP________-Distance to nearest lot li ie►'/ -___-__._ ® Number of lines_______ �_Length of each line------i10_4---__ Width of trench____)__'�_,_______________ Y Type of filter material-�. _-W�,�Depth of filter material-_-l� - ___.__.-Total length-------�__�_/?___________________-- Seepage Pit: Distance to nearest well----------------------Distance from _ 3foundation________________.__•-D>wistancIe to nearest lot line______-_________ -- _ Depth__________.______________-------- Od1 ❑ Number of pits--'--! Lining material____________-______Size: Diameter----- -------- --- Cesspool: Distance.from nearest well---------------__Distance,from found ation_,__-_-_-----------Lining material__________--____________.____________ Size: Diameter--------------------- ----De th------------- -_..Li uid"'Ca acit ❑ ------------- p - -------------------------- q p Y----------------------------gals. Privy: Distance from nearest well__________-___________________________ ________Distance from nearest building___________________________.____-_____. ❑ Distance to nearest lot line-------- ------------------------------------ --------------------------------------------------------------------------------------------- Remodelin and/or repairing ------------------------- ^ --- ----- --- =° -------------------------------- -- ----------------------------•----------------------------------- __....-_ ________- ___________`___-________4!•__ •-------------_-___________________-__---_ - I r ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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 rules and �ulations of the San Joaquin Local Health District. (Signed)--------- - --- -- - ---- ( / ) __ �_ 'l-�rQ�-_____-- Owner and/op Contractor 1 - y 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 ' REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE----------------------------- BUILDINGPERMITISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------- tAlterations and/or recommendations------------------------------------------------ --------------------•---------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- ----------------------- --- -------•-------------------------•-----------------------------=--------------- ' --- ------- ---------- ---- - FINAL INSPECTION BY: '$t - r Date--------- ----- --,:------ --------- - s SAN JOAQUIN LOCAL HEALTH DISTRICT 0 130 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 8-51 Revised W-2100