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APPLICATION FOR SANITATION PERMIT Permit No. ................... (Complete in ,Duplicate) + bate Issued --�-"--J-1_---_-. Applica{ion is hereby made to the San Joaquin Local Health District for a permit to-construct and install the work herein described.. r This application is made in compliance with County Ordinance No. 549. + f �� _. )- JOB ADDRESS AND LOCATION ! ' - [ ----------- '- ------------- -- _____ _ : _ — - Owner's NamekPhone.?� j01,-1Address_--- K -- * ... ----_------ ' ' _ Contractors Name_ _ ! ._______ Installation will serve: Residence ©r Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _1-_--- Number of bedrooms _-Z. Number of baths -_ - 1--- Lot size ---------. ----� - •-----------•Water Supply:Supply: Public system ❑ Community system [� Private ©Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoClay Loam ❑ Clay E] Adobe E] Hardpan El Previous Application Made: Yes L] No � ;eNo New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted if public sewer lis available within 200 � ) I /} .�f�.-. '�' --------�..�„"_ Septic Tank: Distance from nearest weg§N__ `Distance from foundation____ _ _________ atenal___ ---_-- ----_______ v No. of compartments---------- •__Size-----_------------------------Liquiddepth--,-J_--_.._____-___---_--Capacity_-- Disposal Field: Distance from nearest Wei l-._0_rlV'*'�46istance from foundationL�___I?`�"'_`Distance to nearest lot line_. _-_.._. ` Number of lines____________/--------------------- of each-line__b_�`- Width of trench-_- -- 10V Type of filter material__ _ --,__-Depth of filter material-__._/_ ____________Total 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___________.________________________. ❑ Size: Diameter----- ------- ------------------------Depth----------------------------------------------------Liquid Capacity------------------------- .Is Privy:- Distance from nearest well------------------------------------------ from nearest building_________._______--__--______.___.____._. V ❑ Distance to nearest lot line- ---------------------------------------------------------------------•------------------------------- ---------------•---------------------- Remodeling and/or repairing (describe.):--------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- -------------------------------------------------------------•---------------------------------------------•----------------------------------_.....-.._.---•-------------------------------------•-------------------------- --------------------rC4 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I herebt I have prep - ed this 'cation and that the work will be done in accordance with San Joaquin County ordinances, andruesan regulatio s the San Ja quin Local Health District. 5i ned �-._- - Owner and or Contractor9 )------- --- -- ---------- --- ----------- ---------------------- -------------------------- ---- -� 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-------- :: --- -A -� . --- -------------------- REVIEWEDBY------------ ---- --------------------------------------•---------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED----------------------------------- ---- ---------------- --------- DATE--------e---------------------------•--------- Alterations and/or recommendations-------------•---------- -- --" --- ---_----_ --- ----------._.. _.._..-•-- -+ __- -__„--•-- ----------------------------------------------------•----- --------------------------------------- ------------------------------------------------------------ " ,�"--" ' _K ............. "! ----------- . ------------------------------------------------------------------------------- ------------------------------ ----------------------------------------- -------------------------•---------------------------------- ------------------------------------- -------------- ------•-----------------------------------------------------------------------------------------------•---• -•------------------------------------- rsFINAL INSPECTION BY:-------c -- --------- 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 E5-9-2M Revised W-2100