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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 described. This application is made in compliance//with County Orlinance No: 549. JOB ADDRESS AND LOCATION, Owner"s Name-- I----- - I-- --- - _0 ---- Phone-_ _ - Address....... -- ---- 7 ContractorsName---- ------- ---------- -- ------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House [] Commercial E] Trailer Court [:] Mot9l E] Other, Number of living units: -------- Number of bedrooms drooms 2- Number of baths -1.-- Lot size Wafer Supply: Public system El Community system E] Private T(Depth to Wafer Table -------- ft. P Character of soil to a depth of 3 feet: Sand P Gravel E] Sandy Loam Clay Loam IRI/Clay F] Adobe E] Hardpan ❑ 0 * P j, Previous Application Made: Yes E], N ;� New Construction. Yes No 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 El No. of compartments--------------------------Size--------------------------------Liquid depth--------.-----------------Capacity----------------------- Disposal ------------------------Capacity----------------------- Disposal Field-, Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_________-_-____. ❑ ine--------:-------- ElNumber of lines-1-------------------------------------------------------------------Length of each line------------------------------.Width of french----------------------------------- Type of filter ma'ferial-------------------------Depth of filter materiaJ-------------------—jotal length-_-_____________________________-____:__- I Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot line________--_______ ❑ ine----------------- El Number of pits---1-------------------Lining,materiaf-----------------------Size; Diarneteir-------------------------Depth esspo Distance from n restwe4jL_S4;7__Disfance from fou dation_- -`---- -- ---------Lining material C - Size: DiamE -------------Depth---- • ------------ml-----------------------------Liquid Capacity---Z:9 -----------gajs. 4w4kt- Disfance from nearest weli--------------------------------------------- ---Distance from nearest building------------------------------------------ Privy: _Distance to nearest lot line._____________--------------------------------------------------------------------------------------------------------------------------------- Remod g and/or 'r % re Uang (describe). ----- ----�&--------I--------- -------------------------------- --------- r '',1117 -Y-4- ------------ ------- --------------- -- ------------------------ ------ -------- -------------- --------- - - ------------------- -------`-`-`J` ------------------------------------------- -------------- ------------- -plication------ ----------------------------------- --------------------- ----- s I hereby certify that I have prepared this aand that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulai-jons of the San Joaquin Local Health District. (Signed) ••--------------------------111t------ ---------'-- --------_------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------f------ -------------------------------------------------------------------------------(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-- REVIEWED BY- I _1? ------- ------------------------------------------------------------------------------- DATE---------CZ1, BUILDING PERMIT ISSUED------ -- -------------------------- DATE------------ ----------------------------------- Alterations and/oVcommendations---------------- -------------- , ,.., 4 1 ------------------------------ ...... ------ -- ---------------- ----------------------------------------------------- ----------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- --------------------- -------------------------------------------------------------------------------------------------------------------------I------------ FINAL INSPECTION BY:-.---- ........../----------------------------- Date-------- - SAN ate--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100