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APPLICATION FOR SANITATION PERMIT Permit No. ___ ''.LL_________________ (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. JOBADDRESS AND OCAON y� - -------------------------------------------••---------------------------------------------------------------------------- Owner's Name--- k ------•----- XJ Phone Address--------------- �... -------1J-- Contractor's Name---- ---------- 6_4------ -------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial ❑ E]Trailer Court ❑ Motel ❑ Other Number of living units: _L. Number of bedrooms .•Number of baths ._I--- Lot size -------d _-- _. ___-__._.-_---____-- Water Supply: Public system A Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No lj�--.-New Construction: Yes Z_No ❑ � r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank�or cesspool permitted if public sewer is available within 200 feet.) Septicfrom [� Tan nearest well-----------------Distance from foundation-------------------.Material-----_-__-___-------------__-__----._ mpartments----------- -------------Size----------------------------_Liquid depth--------- ----Capacity----------------------- Disposal Field: stance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-__--___--__----- ❑ , f lines----- -----------------------------Length of each line------------------------------Width of trench---------------------------------- Type filter material-------------------------Depth of filter material----------------------Total length_-___---__-_____-----___-___-----__---_ Seepage Pit: Distance to nearest well-'-_, ?-0istance from foun4ation---s ✓ -..Distan e to nearest lot line__---- Number of pits-- --- ------------Lining material---C _4- + � Diameter_._- --__....Depth----- ----------_-- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------------- ❑ Size: Diameter. ---------- ---------------Depth-------------------------- - - Liquid Capacity---------------------- ----gals. Privy' Distance from nearest well-------------------------------------------- --Distance from nearest building._____---------------------_ _ -_._----_.-. ❑ Distance to nearest,lot Tine_:-------------------------------------------------------------------- Remodeling and/or repairing (describe) ----------- ---------------------------t------------------- ------------....------- ----••- t " --------------------------•----------------------------------------------•------------------------------.._..-..-•---------------------------------•----------------••-------------------------------------------------------- '-------------------------------=---------------•-------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- I hereby certify that;I have prepared this application and that the work will be done in.accordance-with San Joaquin County ordinances, Sfrats,-- and rules and regulations of the San Joaquin Local Health District. ' weer and or Contractor k (Signed} -------------- / ) --------------------------------------(Title)---- ------------------------- - ----•-------- (Plat 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 BY7� -------------------- ------------------------------------------------------------ --------- DATE --------------------------------------------- REVIEWEDBY----------------------------- ------------------------- DATE - - BUILDINGPERMIT ISSUED ;�p----------------------------------•------------------------------------ ----------- DATE -------- -------------------- Alterationsand/or-recommendations:-------------------------------------------------------.---------------------------------------------------------------------------------------- ------------------- ------------------------------------------------ ------- --------------------------------------------------------------------------=------•----•-------•--•----------•----•----------------•---------- ------------------•------------------- ---------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------ ------------- ---------- --------- -----------------------------------------------------' - ---- - -------------. ------•------------------------------------------- ---- ------------------------------------------------ FINAL INSPECTION- BY:------'--------- ----- -- Qate .. % `-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreot 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100