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Permit No. APPLICATION FOR SANITATION PERMIT � (Complete in Duplicate) ------ ~�" Date Issued Applica+ion 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. 10 JOB ADDRESS ANDLOCATION-----I_Q-s -'_�-"_-_.-� ` _--- --- ` A-__ -------------- Owner's Name ----------------- Phone Address---------------_ -------- Contractor'sName Name-------- ---- --- --------------------• --------------------------------- Phone----------• - - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __r_.._ Number of bedrooms .-'Y Number of baths J____ 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 ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe fe�Hardpan ❑ Previous Application Made: Yes ❑ No [ANew Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_t4tf1u4JDisfance from foundation_14^-___.__.Material___ -----------------------k-------- 5� No. of compartments_____ ___------------Size �- - E_`_. ___Liquid depth____ _ .��.______._Capacity.- Disposal Field: Distance from nearest we€I__6ZX0___Dista c4 from fdundation___ '____.Distance to nearest lot line____,f4__ _ [ Number of lines------/-_______ Length of each hne__�-'D___' ----------Width of french.__ _`<"__________________ Type of filter materiaL_�_ �r_� ____Depth of filter material------ -----------Total length_____ .Q_'__________._______._ Seepage Pit: Distance to nearest well__M_ 'l6__.___Distance f m foundation---,-Q. __.Distance to nearest lot line...... [� Number of pits------I-------------Lining material-.----- S------Size: Diameter_____. Depth_.o2_V-------._ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- n ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------•---- -----gals. Privy: Distance from nearest well------------------_------------------------------Distance from nearest building_____________.________________.._:______. ❑ Distance to nearest lot line------------------------------------------------•----------------------------------------------- •--- Remodelingand/or repairing (describe):------------------- -------------------------------•------------------------------------------------------------•---•------------------------------------ -••---•--•-------------------------------------------------------------....---------------------------------------------------------------------------------------------------------------••-------------------------------- -------------------------------------------------------------•---------------- -------------•----------------•---------------------------------------------------------------------------------------------------------------- hereb ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to a laws, n and regulations of the San Joaquin Local Health District. (Signed).-------- --------------------------- ------ ------ ------------------------------------------I ---- Contractor) By:----------------------------------------------- ------ ------------ -------------•---------(Title} Q --------------------- (Plot plan, showing size of lot, location of system in rel ion to wells, b ildings, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------- ------- --------------------------------•-------•---------------- DAT -------- - ----------------------------------------- REVIEWEDBY-------------------------------------------------- ------------ ---------------------------------------------------------- DATE------ -----------•------••------------ BUILDING PERMIT ISSUED----------------------- -------------------------------------------------- DATE------------ --- ------- Alterations and/or recommendations:_-____.._ ------- --� -----------•------------------------•-------------------------•------------------------------------------------------------------------------------------•-•--•-------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- i FINALINSPECTION BY:. -------------------- ---•--------• Date------- ------ /------------------------------------------------------- SAN ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "G" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M • Revised W-2100