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APPLICATiON FOR SANITATION PERMIT Permit No.a__�---�--�---- (Complete in Duplicate) Date Issued55-�/ 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. ----------------------------- , --------------- -- JOB ADDRESS AND LOCATION-------_�-�--�------- - - -- - ---- ----------------------------------------------- ._ Phone------------------------------------ ' -----------. - - - -- ------------------- --hon Owner s Name________ q Address--------------------------- ------------- - - ----•---------------------- --------- - IPhone ---- ----- - ------------------------------- Contractor's Name----- - - ------ ----- -- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Nu r of bedrooms __`_� f baths I______ Lotsize -- --------------------- - Number o Water Supply: Public system Community system ❑ ..Private E] Depth to Water Table ____- ft. Character of soil to a depth of 3 feet S ntI'[]• Gravel ❑ Sandy Loam ❑ Cla_y Loam ❑ Clay ❑ Adobe's—Hardpan ❑ a Previous Application Made: Yes No ❑ New Construction: Yes o ❑ � � r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pe!rmi++ed if public sewer is available within 200 feet.) S ptic Tank: Distance from nearest well---------_------Distance from foundation_________-`-_`___.Material_-_-_-_________--___________---_-___-_______ po � No. of compartments--------------------------Size--------------------------------Liquid depth----------- ---------Capacity--------------- ------ Disposal -- -Disposal Field: Distance from nearest well4/�_.Distance from foundation_/-✓—_____Distance to nearest lot line__$-f-__--- f each line - {----------- Number of lines_=_--__ dd_ ____ -Length f trench10 Type of filter material-�VA__ _:---_Depth of filter materiaL _____________Total length--____1'7' _ m___________--______.____ r N% Seepage.Pit: Distance to nearest well-___________-.-------Distance from foundation-------------------- to nearest lot line----------------------------- El Number of pits----------------- ---Lining material -------------------,_,Size:'Diameter-----------------------.Depth-------__-_-- Cesspool: Distance from nearest well------------------Distance from foundation---------------------Lining material-------------------------------------- Size: ❑ Depth------------------- -----.---Liquid Capacity----------------------------9 Size: Diameter-------------------------------------- ------- ----------- - Privy: — Distance from nearest well______________--------------------------------D.istance from nearest building__-_____________------------------------- ❑ ---- -----------•---------------- Distance to nearest.lot line_---------- ----------- -------- -------=-----:----------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------ ----------------------- r --------------- ------------------------------------------ -r - ♦' S --------------------------------- _______ _ ----------------------------------------------------------------------•------- ----------------- ? 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)--------------------- --------- ------ ---- -------------------------------------------------- (0 Fer�and/' r Contractor) _ �7 B ------`----------------------------- (Ti+le = ' Y� r ) (Plot plan, showe-g--size of ot, location of system in relation to wells, buildings, etc., can be pl don reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- __ -_-.t ----------,------ DATE V_;57 I REVIEWED BY---------------- ------------ ------------- ------------ ---------- ----------- ------------------------ -_ -------- DATE--------------------------------------------- ------------ BUILDING PERMIT ISSUED-------------------------------------------------------------------- --------- ----------------------- DATE------------------------------------------------------------- ( Alterations and/or recommendations------------------- ------- ----------------------------------------------------------------•--------------------------------------------- - -------------------------------- ------------------------------------------------------------ t ---------- -------- ------------------------------------------------ - -------------- ------------------ --------- FINAL INSPECTION BY_____________ __ - Date-------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Westoak Street {32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100