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,b APPLICATION FOR SANITATION PERMIT Permit No.f 8_i4.._.... (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 withCountyOrdinance No. 549. JOBADDRESSAND LOCATION------ '----------------------------------------------------------------------- Owner's Name----------------------- -- -- -----------t__ ---------------------- - --------------------------- Phone----------------------------------- Address----------------------------------------- --------------------------------------------------------------------------------------- Contractor's Name------------------------------ -------------- ------------------------ ------------------------------------------------------- Phone----------------------------------- Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑} ! Number of living units: ___!___ Number of bedrooms __ Number of baths _1_____ Lot size ----------- _1-��------------------ Water Supply: Public system ❑ Community system ❑ Private epth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobear'dpan ❑ Previous Application Made: Yes ❑ No slew Construction: Yes U- TYPE OF INSTALLATION AND SPECIFICATION: (No septic tank or cesspool permitted if publiy seypr is available within 200 feet.) Septic Tank: Distance from nearest well_3`40L_Distance from foundation____ ------Mat nal____ -_-__.___. No. of compartments__- Y_---y5ize------- _ Liquid de th_______!e ____________Capacity_____ __ I: Disposal Field: Distance from nearest weli__4_U_. Distance from foundation--/--- ___ --_ _Distance to nearest lot ling.____�._. Number of lines________-____/______.___ Length of each line___--__ _ _____ __.Width of french----__. __ . _v Type of filter material________ __ epth of filter material_______ �r-_____dotal length________/ ._`___ _____________ 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 --_--.______-------________-_.----- 11 ❑ Size: Diameter------------------------ Depth------ ------------------------------ --------------Liquid Capacity------- -------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building___________________,________-_--------_-- +I ❑ Distance to nearest lot line___--------------------------------------------------- ---------------------------------------------------- =------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------=-------------------------------------------------------------------- i ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j ordinances, State laws, and rules a i lations of the San Joaquin Local Health District. a Si ned '=< - A (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----------------- -00c` ------------------------------------------------------- DATE-------144,1/A c57----------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE---------------------- ------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations ----- - ------------------- - ---- ---------- -------------------------------------------------- --------------- ------- .i _C�e_ :------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- 11NAL 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 8-51 Revised W-2100