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APPLICATION FOR SANITATION PERMIT Permit No. ___��_�, _ (Complete in Duplicate) ,. , - / Date Issued 9r� 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 A ION--------------- -41r .1o -- - -4-------- ------------------ ------•-------------------------------------------------------- Owner's Name ---..... ------- ------ Phone--- // a -------- Address Y - �---- --- ------ -- ---- ------------ Contractor's Name --------- ------------ ----------- Phone------------------------ - ---------------- Installation will serve: Residence 2<Aparfment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/__ umber of bedrooms __Number of baths ___L Lot size _-�_ s_� � ,, �_ --------__ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑„ Clay Loam E] Clay �fidobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes YKO'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-�'"�----Distae from,fougdation_1D__-,.------Material-_____ ___________ No. of compartments-------I---------------Size--Z-A?-X--1C - Liquid depth---?_---------------_Capacity I Disposal ield: Distance from nearest weil7" /t, Distance from foundation__V"*-__Distance to nearest lot line--j- I_--_-- i pNumber of lines_________1___ _,- r Length of each line r- Width of trench r----------------- ` Type of filter material-1 ?• --Depth of filter material----/__________:___Total length------ _-2"-------------------------- I Q____________--_I Seepage Pit: Distance to nearest well----------------------Distance from foundation----.---------------Distance to nearest lot line_____---_____-___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth----------__------------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- material-_____--_____________ _ El Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity------------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------.-___________________ Distance to nearest lot line ' :---_---------------------------------------------------- --------- ------------------------------•---- ------------------------------•- Remodeling and/or repairing (describe} F - -------------------------••------- -----------------•-------------------------------------------•----- --------------------------- - - ------------------------------------•------------------- ------------------------------------------------•-------------•------ ------------------ ----------- ---------------•------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, d rules and regulations of the San Joaquin Local Health District. �� (Signed) ue— _ ------- ---------------------(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). r FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY- T - ---------- ----- -------------- DATE_ ��------------------------_ REVIEWED BY -------------------------------------------- DATE = � BUILDING PERMIT ISSUED --------------•---------------- ------------------------------------------- DATE 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 8.51 Revised W-2100