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j APPLICAf[ON FOR SANITATION PERMIT Permit No. Complete in Duplicate) c Date Issued ----------------------- Application is hereby made to the San Joaquin Local Health�tiE for a rmit to construct and install the work herein described.. '! This application is made in compliance with County Ordinance No. 549 f 11 JOB ADDRESS AND LOCATION- s ----- _-_ 0-30 —Q -- ----- _� _ - - - --------------------------------------j-- --------------------- f �j --- r---------- - -------------•-- Owner's Name--------- ------ ----- -- ------- Phone------------------------------------ ---- ---------------------- s s --------•--- - w_Address Contractor's Nam --- - - --"f---- ----- '----------------- ----- Phone��_� �_---------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote] 1k Other El1k Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ____________________ _ ---------------------------------------- r 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 0 Adobe ❑. Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ il TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan : Distance from nearest well_� _Distanc_e fr tion---- ` Material- No. of compartments Liquid depth__-,r� -�I— _ -❑ - - Ca aciY-- --- -------- Disposal Field: Distance from nearer# well------------------i Distance from foundation____________-_____.Distance to nearest lot line----------------- ❑ Number of lines------------------------ ------Length of each line------------------------------Width of trench 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-----------------------------9 1 Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_--_____-if--------------------_____-_______-____Distance from nearest building 9 -- ----- ❑ Distance to nearest lot line------- `--- ------ ---------- V� - ---------------------- -----------------------•--- ------iRemodeling and/or repairing (describe):"_________________;__ _ ----- --- - --------------------------------------------- ------------------------------------------- --------------------------•----------------'� --- ----------- ------------------------------------------•---------------------------------------------;----------------------------------- -------------- l------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawa. and rules and regulations of, the San Joaquin Local Health District. 3 (5i ned .- caner 9 =" _ - and/or Contractor` B h r � r ' -------------------------------------------------------------------•---- Title- r , ( le)- (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be place on rever side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-SQ, DATE__ ---- ------------------------------------------------------------ -------------------------------------------------- REVIEW ED BY DATE------ -------- -- t BUILDING PERMIT ISSUED------------------- DATE ------------------------------ Alterations and/or recommendations----------------- = --------------------------------------- ------------------------------------- --------------• ----------•-----------------------------------------------------' ------------ -- ------------------------ ----------------------- - --- ------------------------------------------------------------------------------------------------ -------------• , ---------------------------------------------------- -------------------------------------------------- F d. s: FINAL INSPECTION BY------- ----=---------- -- -------------------- Date,-------`- 1- _ u SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore S+reet $l4 North "C" S+ree+ I Stockton, California Lodi, California Manteca, California Tracy, California ` II ES-9-2M 8-51 Revised W-2100 i ..