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APPLICATION FOR SANITATION PERMIT Permit No. __�_/ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein ribed. This application is.made in compliance with County Ordinance No. 549. JOB ADDRESS AY3)LOCATION-- -------------- ----------- ------ Owner's Name---- -- ----------- --- ----- --- -- - -------- ---------- ---------- -- PhonS--------------------------------- Address ----- - ----- IIL-,3-.O-- --------------------- ---- ------------------------------------------------------------------------------ Contractor's Name------------ ------ ------------------------------------------------------------------------ ---------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court El, Motel E] Other E] Number of living units: Number of bedrooms❑ _--le/Number of baths __/__ Lot size'. Water Supply: -Public system Community system ❑ Private X Depth to Wafer Table Character of soil to a depth of 3 feet: Sand [:] Gravel [] Sandy Loam E] Clay Loam E] Clal ❑ Adobe E] Hardpan E] Previous Application Made: Yes E] NoNew Construction: Yes Noj�� x E] 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--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- �► Disposal apacity----------------------- D;sposal Field: Distance from nearest well---------------.-Distance from foundation---------------------Distance to nearest lot line_.._____._-______ ❑ ine----------------- El Number of lines-----------------------------------Length of each line-------------------------------Width of trench----------------------------------- Type rench--- --------------- --------------- Type of filter material--------------------------Depth of filter material-----------------------Total length______________--______________-__-____--._ O Seepage ength------------------------------------------ Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line----------------- r❑ Number of pits----------------------Lining material----------.-----------.Size: Dia//meter----------.------------.Depth-------------__ ------ --- Ce ol: Distance from n f ell 1690 Distance from foundation...AP Lini �uo material Size: Diameter--- Depth------- ---------------Liquid Capacity_ --- - Privy:' Distance from n -------------------------------Distance from nearest building_____..._._.____._ -_ ❑ uilding---------------------El Distance to nearest lot line-------- ------------------------------------ ------------------------------------------------------------------------------------------ --- - -------- --- Remodeling and/or repairing (describe):_& 71rr-4r------ ------------------------------------------------------------------------------------------------------- ---- ------------ ------- _/----------------------------------------------------------------------------------------------- ----- ------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ------------------------------------ ---------------- -------------------------------•--•------•------------------------------------------------------------------------------------------------------------------------ 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).. L716z,�, - I --------------------------------------------- -- -----------------__----------- ----(Owner 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---- --------------------------------------- -- --------I---------------------------------------- DATE-------------------------5�y--------------------------- REVIEWEDBY-------------------------- ---------- ----- - ----------- ----- -- - ---- --- ---------------------------------------- DATE---- ---------------------------------- BUILDINGPERMIT ISSUED------------------------------------- - -- - - ------------------------------------------------- DATE-- ------ -------------------•-•----------- Alterations -----------------------I------ Alterations and/or recommendations:---------------- --- -------------------------------------------------------------------------------------------------------------------------_--------------- ----------------------------------------------------------------------------------- ---------------- ---------------------------------------------------------------------------------------------------- --------------• --------------------------------------------------------------------------------- -------------------------------------------------- ------------------------ --------------------------------- --------- -------------------------------------------------------------------- ---- ------------- --------------------------------------------------------------- -- -------------------------------- ------------------------------ ---------------------------------------------------------------------------- --- ... ---- - ------ -- ------------- ------------------------- ------- -------------------------I----------------------- -------- FINAL INSPECTION BY------------------"! -- --- ------------------ -------- Date---------- -- 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-9-2M 10.52 Revised W-2100 I .