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APPLICATION FOR SANITATION PERMIT Permit No. �---_�__`_-- (Complete in Duplicate) Ap Date Issued __ ______ -------- Application is hereby made to the`San Joaquin Local Health District for a permit to construct and install +he work herein de ed. This application is made in compliance with County Ordinance No. 549. .4 ----�--;;�� JOB ADDRESS AND LOCATION._.�.... ��` ►-- ! .A � Owner's Name V� �r 't' ._--------. ------------------------ Address---------_------?--- �- Contractor's Name------------------ ----•----------------------------------------------------------------------•--------------- ------ Phone.----------------.---------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ -__ Number of bedrooms __.2_ Number- baths _/_____ Lot size . _ ________________________ Water Supply: Public system ❑ Community system ElPrivate Depth to Water Table _. ft. _ Character of soil to a depth of 3 feet: SandGravel ❑ Sandy Loam ❑ Clay 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 public sewer is available within 200 feet.) \\\ Septic Tank: Distance from nearest well___ ....... from foundation___lA-----------Material---- ❑ No. of compartments------------ ____________Size_ ___X_777_ __________Liquid de th_-_-_--_____ _Capacity Disposal Field: Distance from nearest well-_57V-------Mstarice from foundation____,{3'---__Distance to nearest lot line__0-�_o_____._. ❑ Number of lines_ ______________ __--__---Length of each line_ '-!'Sr:_--a(_-Width of trench_!fK�-______________________ Type of filter material.?P—c&--------Depth of filter material___l f` Total length_/.a d_�_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation----....________.._.Distance 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. s Privy: Distance from nearest well--________-_-________ -------------------------Distance from nearest building------------------------------------------ 171 Distance to nearest lot line Remodeling and/or repairing (describe):-_---��r �'-------------------------------------------------------------------------------- 1 -------------------------------••-----•---•---.----------------------------------------- ---------------------------------------------•- ----------------------------------------------------------------------------------------••--------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, fate laws, and rules and re ulations of the San Joaquin Local Health District. d/o/_/ (Signed)._` ------ ---------------------------------------------------------------------------------------------- ------{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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- --- --------------- - DATE-_ ---- --------------------------------- REVIEWED BY ----------------------- DATE_ --- - --- ----------------------------------- }}�� BUILDING PERMIT ISSUED l _ >f�'-------------------------- - ------------------------------ DATE-------------------- `- - Alterationsand/or recommendations---------- -------------------------------------------------------------------------------------------------- ------------------------------------------- --------------------------------------------------------------------------- ---------------------------- --------------------------------------------T------------------------------------------------------------ : ------------------------------------------------------------------------------------------------------------------------ -------------------------- --------- --------- --------------------------------------------- FINAL INSPECTION BY: "!'Lr----------- -------- ---------------------- Qate � �� ---------------------------------------------------- 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 5 ES-9-2M B-51 Revised W-2100