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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) f D` Date Issued 0CpZ—ZC,0-3� Applicaa-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein scribed. This application is made in compliance with County Ordinance No. 549. . _ :.. = �f------------------------------�"----- JOB ADDRESS AND LOCATION _ _ _ _ __ _.-- --- / - -------------------------------- -- Phone ------------------------------------ ------------------ Owner's Name---�-�"�-------�'------•- ----- -- -- ---- - ------ --------------------------- - Address.---- �o-1!�--------- --------------- Contractor's Name, - ?- ---'-'•`-----•--------------------------------------------------------------------•--------------------•------•-------- Phone ............... _------------------ Installation will serve: Residence [t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I ----- Number of bedrooms _�a--- Number of bathsl " Lot size ------------------------- Wafer -----------------Water Supply: Public system ❑ Community system ❑ Private W Depth to Water Table 41 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam P@ Clay Loam ❑ Clay ❑ Adobe [] Hardpan ❑ Previous Application Made: Yes ❑ No O� New Construction: Yes L? No ❑ 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_4 ----- Distant*fro f�oundation_�Q____.-.._...Mat ___________________ No. of compartments ----- �_.---__---._--_.Size_ ___�`_____a___Liquid depth____________________Capacity_f*_._ �V-..-_-----.Distance to neareswoj.Gne_ 77�------. w Disposal Field: Distance from nearest well -_o5 _ �_.._ Distance from foundationZ.0 4ii j Number of lines 0-1 Length of each line-_ - ---- ---------Width of trench ._-____-- __ f�-_-------..----_--- Type of filter materia _ lC� Depth of filter materia!__ ._ f Total length_`"_________.._ _ -% - ' +� Seepage Pit: Distance to nearest we ----------------------Distance from foundation El to nearest lot line_________________ (�1� ❑ Number of pits- --------- ------------ Lining material ----------------------- Size: 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 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. 41 (Signed) ----- � ... 1 ----------- ----------------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------ ----- ------------ -----------------------------------------------------------------(Title)----------------------------------------------- ---------------- (Piot 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__/Q_ /� --------------------------- REVIEWED BY ------------------------------------- ---------------------------------------------------------------------------- -- ----- DATE-------•----------------------- ---- ------ --------------- BUILDINGPERMIT ISSUED ----------------------------------------------------- =--------------------- ._------------------------ DATE ---------------- ------------------------------ -------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: ---- tA------------------- Date -------P_-------------------------- ----------- ------------------------------------ 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 ; � Revised W-2100