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APPLICATION FOR SANITATION PERMIT d Permit No. (Complete in Duplicate) �9��02 d Date issued -----------/-------- Applioation 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. JOBADDRESS AND LOCATION...2 2�L ----------------�''-•------ �----------------------------------------------------------------------•---------------------- Owner's N ---------- Phone------------------------------------ Address---- ........ - _ _".. - Phone------------------------------------ Address--- .._.._111!.---- •--------------------------------* --------------•-------------------------- Contractor's --------••-------•------- Contractor's Name------- -------••-----------•-•--•-----•----------•----•--•------------------------------•---------------------------•----•--. Phone----------------------------------- Installation will serve: Residence D--p rtment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/_ Number of bedroom___:_ Number of baths f_____ Lot size . A '. ___-_-"-----_____.____ Water Supply: Public system 6W-11C—Immunity system ❑ Private ❑ Depth to Water Table -------- 4.11 Character of soil to a depth of 3 feet: Sand ❑ Gravel E❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe hardpan ❑ Previous Application Made: Yes ❑ No Ogolllew Construction: Yesto ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T04Distance from nearest welll��__Distance om foundation--- �_J_----------Material _____ No'. of com arfinents_ Size Li uid depth---------f % ---.Ca acif -- -�-,------ pisp sa 'field: Distance from nearer well__/ Q _Distance from ,foundation___/_ ._______.Distance to nearest lot line__1.5 �____ I Number or lines__'____._.___- Len th of each line.............. r g _l_._.Width of trench._ a_ �� Type of filter material-------, __/---Total length---,� �_�___ _______________ T e of filter material_______ __ Seepage Pit: Distance to nearest well----------------------Distance from-foundation_________.-_-_-___ Distance to nearest lot line__.._.____.-____- ❑ Number of pits---- -----------------Lining material Cesspool: Diameter Depth - Cesspool: Distance from nearest well________�_______Distance from foundation__.________.._.__RLining material_________________________--__.______. ❑ Sizc: Diameter---- ------------------ -----------Depth-------------- -------------._.._:-Liquid Capacity-----------------------"----gals. Privy: distance from nearest well __________-------_------_-----------------------Distance from nearest building �1 ❑ Distance to nearest lot line-------------------------------------------- ri Remodeling and/or repairing (dascrihe)----------------------------------------------•------------------------------------ ------------------------------------------ ------------------------- --------------- --- •-- ---------------------•-------------------------------------------------------------------------------•---------- ------------------- ------ ---•----------------------------------------------------------------•------------------------------------••--------------------------•------ ------------------------------------------------------------------•-----------•-----------•---------------------------------------------------------------------------------------------------------------------------- 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 rules and:regulations of the San Joaquin Local Health District. (Signed)-• -f r . c /`" e,4- 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 --------- - -- ----------------------••------------------------------------ DATE REVIEWED BY----------------------------------------- ------------------------------------------------------------ DATE---- - ._ BUILDING PERMIT ISSUED------------------------ --------------------------------------------- ------------- DATE------ --�. ----------- ----------- -------------------------------------------------------------------------------- Alterations and/or recommendations: r ------------------------------------------- - ------------------------ ---------------------------------- ------•- FINAL INSPECTION BY:.... ! !~ Date--------------------- ---------------------------- i 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-1-2M io-s2 Revised W-2 1b0