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APPLICATION FOR SANITATION PERMIT Permit No.`5�_.O_... (Complete in Duplicate) Date Issued Applica+-ion 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 TION__________ _ ____.___ _ -= = ---�"' == - �j l�---------- Owner's Name_ -`_"4 _1_-- 01 - -u-==---- ..�.�s„.��- -- --- ----------------------------------- ------ Phone ------------------------------------ Address------------------------------------------------------------------------=------------------------- �------------------------------------------------- ----------------------------------------------------- Contractor's Name ------------------- '`�-'2; .----------------------------------------------------------------------------------- Phone ----------------------------------- Installation will serve: Residence �artment House ❑ Commercial ❑ Trailer Court ❑' /Motel C]Other ❑ Number of living units/ -------- Number of bedrooms -- ,Number of baths /------ Lot size --- ,l�-�___ �"'1_.�_____________ Water Supply: Public system ❑ Community system ❑ Private a --Depth to W Table ______ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pubc wer is available within 200 feet.) - ^ Septic Tank: Distance from nearest well. Distance from foun>a#ion___ __.Materi ____ ______."t"�________. No. of com artments--------- Size t p ------Liquid de . h----------'-�1------------ CapacitY-- -- ---- --------- Disposal Field: Distance from nearest well ----- ' ._ Distance from foundation__ -____._________.Distance to nearest lot line _________-______ Number of lines_._________ _____�_ Len th of each line__ __ 0% �_ _._._44.>V ldth of trench___-- _. `' Type of filter mate ria l�j� �_%--Depth of filter material ----t__ - -------.Total length -_Y- - ---- --------- ---------- ___.D tante to nearest to line_________________ Seepage Pit: Distance to nearest well __________._______Distance from foundafion________________ is ❑ Number of pits ---------------------- Lining material ----------------------- Diameter ----------------------- Depth ___________________________,� Cesspool: Distance from nearest well ----------------- from foundation_ ---_____._____Lining material___________________________________ ❑ Size: Diameter------ ------------------------------- Depth ----------------------------------- ---------------Liquid Capacity ---------------------------gals. Privy: Distance from nearest well ______-____________________._____.__.__---- Distance from nearest building ------ ____________________________- ❑ Distance to nearest lot line------------------------------------------------------------------- ------------------------------------------------------------------ Remodelingand/or repairing (describe): ------------------------------------------------------------------------------------------------------------------------------------------------ -------- ------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- 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. ' 1- - --' " - --------------------------------------------- By: ---------------------- - (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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------,".° ------- ------------ --------------------------------------------- DATE------- REVIEWEDBY------------------------------------------------------------- -------------------------------- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED ------------------ ---------------------------------------------------------------------------------- DATE------ --------------------------------- -------------------- Alterations and/or recommendations------- ------------------------ ----------------------------------------------•----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ------ --------------------------------------------------------------------------- ------------------------- - - - - - - - - - - - - --------------------------------------- --------------- --------------------- - ----------------------------------------- - ------------------------ - - - - - - - - -------------------- - ------------ - --------------------- - - - ------------------------------------ ---------------------------------------- Date_-...:._ ---------- --- -----_---------- ------- ------- --------.. FINAL INSPECTION BY:______:._ _"'�'_-_"�. � � 130 South American Street Stockton, California ES -9-2M ; IRevised W-2100 SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California