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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 Ordinance No, 549- JOB,ADDRESS AND LOCATION: OCATION ---- © ~_ Owner's Name-------------11" -1,------- - -----------------k- -------------------------------------------------•----- Phone--- '+�— ------ Address----------- ------------ --------------"-----------------------------------------•---------------------------------------`-----------------------------.. Contractor's Name---------- ---------- -- ------ -------------°--------------------------------------------------------------------------------- Phone.-•-------------------------------- Installation will serve: Residen 1e (( Apartment House ❑ Commercial ❑ Trailer Court ❑- Motel ❑ Other ❑ Number of living units: _!_____ Number of bedrooms 3__ Number of baths Lot size ------------------------ Water Supply: Public-system El ' Community system ElPrivate [Depth to Water TableS%s7ft. Character of soil to a depth of 3 feet: Sand E] Gravel [jSandy Lo;?No Clay Loam E] Clay E] Adobe E] Hardpan ❑ Previous Application Made: Yes C] No [� New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is'available within 240 feet.) tt Septic Tank: Distance from nearest well_?-�± -Dista f'``fr7o� n foundatison_,-a___________Mat9rial__ �`�[________________ _ POO No. of compartments-----_�--------------`ize__11�__�__�, ------Liquid depth_--------------------Capacity �--��-.---- "� �. ��.,,...� - Disposal Field: Distance from nearest well_+ 4S_P_.Distance from founda ionsP_�Sc�.7_-_�_-______Distance to nearest lot l e_!�_-__._-._ Number of #roes___ Length of each line__ _ ____ __ _ _______Width of trenchJ-10- --------------------- Type -�------------------- 9 E�of filter material_________-Depth of filter material_____1- ---_______Total length______ ________________________ 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----------------- from foundation-------------------.Lining material.---__-_----____________________--___. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance fromnearestwell________________________ ____________________Distance from nearest building__________._________-_-__---_________.__. . ❑ Distance to nearest lot line--------------------------------------------- -------------------------'------------------------------------------ ------------------------ { Remodelingand/or repairing (describe):-----------------------------------------------------------------------------------I--------------•-------------------------_------------ ----- ---------------------------------------------------------- _______________________ A 4 ---------------------------------------------------------________________________________________________________________________________________________________________________________________ -----------------------------------.--------------------------------------------------------------------------------.----------------------.------------------------------------------------------------------------------------ 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules Xanregulations o the San Joaquin Local Health District. ---------- ----------= (Owner and/or Contractor) J2 ---- --- BY:---y-----------------------------••----------------------------------------------------------------------------------------------(Title)---------------------------------------I----------------------- (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 r ------------------------ REVIEWED BY --------------------------------------------- DATE--- ---"-`---�-"" BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- ------ DATE-------------------- - Alterations and/or recommendations:------------------------------------------------- -------------------------------------------------------------------------- - ------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------- ------------ ----------- ---------------------------------------------------- FINAL INSPECTION BY:----------=`-�1� Date �` i f 'f f = 3 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