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� APPLICATION FOR SANITATION PERMIT Permit No -_S'- -_oJ D' K [Complete in Duplicate) a r / ' .� Date Issued _±�--_- C� �•�� r 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 with County Ordinance No. 549. 6 JOB ADDRESS AND LOCATI ------------ --------------------------------------------------------------------------------------------------------------- Owner s Name--- ` ---•------------------------------------------------------------- Phone r Address------------------ -- -------- - e -------------------------------- - Contractor's Name---- --------------------------- - - -- -------------------------------------------------------------------------- Phone------------------------_ -------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I ❑.--- Number of baths ---I--- Lot size //Other. [Ir _- _sx_j-I- ------------------------ Number of living units: -_--�-- umber of bedrooms -_1 Water Supply: Public system [}Community system '[I Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe 0-_'/Hardpan ❑ Made: Yes No New Construction: Yes No ❑ Previous Application ❑ � Q _ �V TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public Ter is available within 200 feet.) Septic nk: Distance from nearest well-_ -- ---Distance fro fou da tion----I Q______-.Materialf-_ r �«- y�y ue No. of compartments-------- -Si e_ sa� tL _-__Li th____---- q id dp Dispos Field: Distance from nearest well._�-_s----- tance from foundation__-0-_- --Distance to nearest lot i -____.._.- Number of lines------------ - ---� / -Length of each line--------6-. - -f�---Width of trench---,.A ----------------•-- Type of filter material �C---Depth of filter material-------/-- ----Total length Type 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----------------------------gals. Privy: Distance from nearest well---------------------------------- ----------Distance from nearest building------------------------------------------ I] Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------••----------------------------------------- --------------------------- ---------------------------------------------------------------------------I------------------------------------------------------------------------------------- ------------ 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 rule and regulations of the San Joaquin Local Health District. L :••= --• ----- ---------------------------------------------------------------------- Owner and/or Contractor) (Signed)_-_....-_-- 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------------ ---------------------------------------------- BUILDINGPERMIT ISSUED---------------- ------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations-----------------------------------------------------------------------------------------------------------------•-----------------------------•------•--•---- --------------------------------------•--------------------------------------------------------------------------------------------------------..-------------..--------.--------------------------•--------------------- -------------------------------------------------------------------------------------------------•------------------------------------ ----•--------------------------------------------------------------I--•-----------•-•- ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- FINALINSPECTION 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