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v APPLICATION FOR SANITATION PERMIT Permit No. _-�_ - �� [Complete in Duplicate] f Date Issued _____ Applicion is hereby made to the San Joaquin Local Health District for a permit to constr ct and install the work herein described. Thi's application is made in compliance with County Ordinance No. 549. f JOB ADDRESS AND LOCATION `-� ------ - ------------------------------------------------------------------------------ t Owner's Name--------------------- ----�--- ------ -� Phone Address----------------------------- z ' - -- ------------------------------ --------- LS r e "Contractor's Name-------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ---- N er-of bedrooms A___ Number of baths ---I--- Lot size _ __ __ ----------------- Water Supply: Public system Community system ❑, Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand�N, l ❑ Sandy Loam ❑ y Loam ❑ Clay ❑ Adobe r pan ❑ Previous Application Made: Yes ❑ No nstruction: Yes o ❑ 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_________________Distance from foundation-------------------.Material------------------------------------------------- ❑ No. of compartments e Liquid depth Capacity D i s p o s a 1j,Field . Distance from nearest well-M6 -_ istance from foundati.on__- _____-Distance to nearest lot ne__ _fl_______ 00 Number of fines___--_ ---- Length of each line-_ � -- __ 4____-.Width of trench--- _ ------------------------------ @ � .Type of filter,materiai_�€ _ - -t---Depth of filter material.___ __ _Total length_____- . __ _______________________ N Seepage P* r Distance to nearest well____________________t Distance from foundation-------------------Distance to nearest lot line----------------- EEINumber,of pits----r-----------------Lining material__-------------------Size:_Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-____-_________Distance from foundation--- -------------.-Lining material------------------------------------- Size; --__----_- ___________-_________- Size: Diameter----- --------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well---------------------------------------------------Distance from nearest building---------------__-___________--__-_------. ElDistance to nearest lot line----------- ---- -- ---- ----------= ----------- ------------------------------------------------------------------------- { Remodeling and/or repairing (describe)----- --- ---- ------ -------- - •-•-_- - = ------------------- --------------•----------------- I --------------------------------------•------------•-------,-------------------=-----------------------------------------------------.-.------------------------------------------------------------------------------ �I ------------------------------------------------------------1-----------------------:------------------------------------------------------------------------------------------------------------------------------- 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 d rules and'-re do of the San oaquin Locai,He Ith District. [Signed)-- �(%OZWand/or ntractor) 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--_�Z.`-------------------------- ------------------- ------------------------------1-------------- DATE---e- REVIEWEDBY------------------------------ DATE--- m ---------------------------------;-------------- DATE-------e-------- BUILDING PERMIT ISSIJED--------- - -------------------�----- ----------------------------------- ---- --------- --------------------------- Alterationsand/or recoinmend ations-------- ---------------- --------------------------- -------------------------------- -----------------------------=-------------------------------- �; . -------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------=-------------------�--,s--------------------------------------------------------------------------------------- --------------------------------------'--------------------------------4-- ---------------------------------- ----------------------------.-.------------------------------------------------------------------------------- FINAL INSPECTION BY:_------� ---------------------------- Date-- __ - --------- ------ -- I-------------- SAN - -_SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes* Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100