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APPLICATION FOR SANITATION PERMIT Permit No. ---_______ __--------- (Complete ___(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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO ATION---- ------- ---- --------------' � � = --------------------------------------- Owner's me �' '---- Ph one------------------------------------ Aki Address 1 � --------------------------------------------------------------------------------------------------------------------- Address Name---------------------- ------------------------------------ Phone----------------------------------- Installation will serve: Residen e N' Apart. ent House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ < Number of living units: _7______ Number of bedrooms _Number of baths __�__-_ Lot size -------------_________ { 1 Water Supply: Public system ❑ Community system '❑ Private)k Depth to Water Table 4_6__ ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe E] Hardpan E] Previous Application Made: Yes ❑ No New Construction: Yes No F] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well__JO.G_' Distance fro fouclp ion----1__a---------M trial_____ No. of compartments______0___ Liquidepth Caciety- ------ --- pa I Disposal Field: Distance from nearest well__ _____.Distance from foundation___ Distance to nearest lot lie_ ______ yy Length of each line__ _ ______ Number of linas_________ --;177h �--Width of trench____ Q____-_____'______---_- --------------- - Type of filter materialCDepth of filter material------ .......Total iength---q.0--------------------------------- ------ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line____________---__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- (1� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-___--__---________________________. ❑ Size: Diameter--------------------------------------Depth---------------------------------- -------- Liquid ---------------------- ----ga . _ ->, _mCapacity s - �" " _Distance from nearest buildin Prwy: Distance from nearest well--------------- --------------------------- g ❑ Distance to nearest lot line-------------------------------------- ---------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):... t=------------------------------ ------------------------------------------------------------------------------- ---------•--=----------` --------- - ------- - fl_ �- ------ afar I' /_--_--' -�----•--- - '� ~` `� I hereby certify that I have prepared this applicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd ru1 and r ons of he San Joaquin Local Health District. --------------------(Owner and/or Contractor) (Signed)---------- -- ---- By:---------------- ----------------------•-----------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan,�showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY______________________________ _ DATE-------------- ---- - ---- -- -------------- ---- -- REVIEWEDBY--------------------------------------------- ----------------- -- ----------------- ------------------------ DATE- --\D- ----------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------- ---------- ----------------------------------- DATE Alterationsand/or recommendations------- ---------------- ----------------- -------------------------------------------------------------------------------------------------------------------- I -----------------------------------------------------------•------.-....----------------------- ----------------------- ••-------------------------------------------------------------------•--------------------------- r ---------------------------------------------------------•------------•------ ------------------------ •----------------------------------------- , � A FINAL INSPECTION BY-------------- ----------------k4 --------- 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 B-51 Revised W-2100