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APPLICATION FOR SANITATION PERMIT Permit No.4____________________ (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. r JOB ADDRESS AND LOCATI Nu --�_ - a-- -------------------------•-•-•---------------•---•---------------- Owner's Name------------------------ - -------------- ----- --- ---- ---- -- ----------------------------------- Phone----------------------------------- Address.......---------------------------------------------------------------------------------------------------------------------------------------------------•------------------------.------•------------------ Contractor's Name---------------------- --• ti!1. !`� ` Phone.: Installation will serve: Residence W Apartmerff House'❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: -------- Number of bedrooms __-----. Number of baths -------- Lot size _----- -1__ -- ,,-__- --------- '" Water Supply: Public system ❑ Community system ❑ Private k Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobe)�r Hardpan ❑ Previous Application Made: Yes ❑ No;E;,,New Construction: YeN 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_�1O_____4Y( Distance efrom #ound tion___._ ___:____-.Material____�-- No, of compartments_______ ---------_-Size_ __Liquid depth_____L " ____..Capacity---- Disposal Field: Distance from nearest we{I_S V__)kDiOance from toundation_- _Distance to nearest lot line_____ \ Width of trench.___ Number of lines_________ _:Length of each line--- ____ -_ � ---- -- ----- Type of filter material___��---------__-Depth of filter material_.__,,i E`._->-____Total length___.----4--aa_______ ________ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line-----------------In ❑ 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 nearesf building.____..-____-.__-.-----_-_______-__....._. ❑ Distance to nearest lot line--------------------------------------------------------------------• -------------------------- ------------------------------------------ Remodeling -Remodeling and/or repairing (describe)----------------------------------------------------------•-----------------------•--------------r------------------------------------------------------- ---------•-------------------------- ••-------•-------------•---••--------.-...---------------•--•--------------.--------------------------------.-.-------------------------------------------------------------------r--- 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. (Signed (Owner and/or Contractor) - bl _ & By----------------------------------------------•-•------------------------------------------------------------------------------------(Title)------------------------------- --------- --- ------------------ (Plot ------ (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------- 1 REVIEWEDBY------------------------------------- ------------------------------------------------------------------------------------- DATE--- ------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------- r---- ------- ------ DATE--------------------- ---------------------------•----------- Alterationsand/or recommendations:----------------- - --------------------------- -----------------------------------------------•-------------------------------------------------------------- ---------------------------•------------------------•--------------•---•------------- --------------••------------------------•--------------------------•------------------------------------------------••-•-----•----- ----------------------------------------------------------•---•--------------------------------------------------------------------------------•--------------------------------------------•--------------------------- --------------------------------- ------------------------- ---I-------------------------------------------------------------------------------- --------------------------•-------------- ---------------------------------- ------------------ ------------------- -------------------- ----V ---_-------------------------------------------------- ------- --1--------------------------------------------- z 53 FINALINSPECTION BY--------------------------- ----------------------- --- Date ------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California ' Manteca, California Tracy, California t ES-9--2M 10-52 Revised W-2100