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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 ii"'compiiance,with County Ordinance No. 549, Lpp JOB'ADDRE5S AND LOGATI , ! jv ----- ---------------------------•----------------------------------- _ Owner's Name-------------------1��--- - --�+------ ----��-�----•---------••-- ----------- Phone------------------------------------ PW /7 ---------- --- - -:----- -- ----�-------- Address f '� .a �'' - Contractor`s Name------------ ------ -•----------------------------------- ---------------------------- Phone.------------- Installation will serve: Residence ® Apartment House ❑ Commercial Trailer Cour} �� ❑ ❑ Motel ❑ Other ❑ Number of living units: __�__ Number of bedrooms _A__ Number of baths __/___ Lot size Water Supply: Public sys em ❑ Community system ElPrivate ® .Depth to Water'Table ________ ft. Character of soil to a dep1� of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Eo Hardpan ❑ ! Previous Application Made. Yes ❑ No ® New Construction: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or �esspool permitted if public sewer is available within 200 feet.) I Septic Tank: Mstanae from nearest well____"_�-__Distance from found a�ion___./D--------Material______ -_ __ ®( No. ofqlcom artments.........Z ______- - _ Size_ .Liquid depth- 7' ------.--Capacity_Z' OTa - ------------ W Disposal Field: Distance from nearest well--- -_v ..__.Distance from foundation---2Q ._____. -_ Distance to nearest lot f ® Number of lines _ ._._____.._ - Length of each line----- Width of trench.__.___�_ Type of filter material---5Ad�t'----Depth of filter material_____ — -- ---Total length----------- ..... ------ I Seepage Pit: Distan Ne to nearest well----------------------Distance from foundation____•________..__--.Distance to nearest lot line__._____________ ❑ Numb eM of pits----------------------Lining material----------------------- Diameter------------------------Depth--- - ----------------- ------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------ Size: Drameter--------------------------------------Death----------------------•-------- --------------- - Liquid Capacity----- -------------- -- --gals Privy;, Distan�IIIfrom nearest wwell______. ____---------------_------------_ .-.--Distance from nearest building ❑ Distanc to nearest lot fine----- Remodeling and/or repairi g (describe)_------------------------------------__ __. ----•----------••------- ---------- -----•-- •---•--•------------------- - ------•---•------------------•---------------------------------------------------------------- . - --------------------------•-------------•-------•-------•----------•--------------------------------------------------------------------------------- I hereby certify that I;Ihave prepared this application and that the work will be done in accordance with San Joaquin County ordinances,State laws, an6'rulesand regulations of the San Joaquin Local Health District. (Signed)__11 �' �" . •. --------------------------------------- -------------------------(Owner and/or Contractor) . -..------ •---------•------- -------------------------•----------------------------(Title)--------- ---------------------- (Plot plan, showing size of Ist, location of system in relation to wells, buildings, etc.; can be placed cn reverse side). - FOR ART ENT USE ONLY APPLICATION ACCEPTED BY.... -- / II - r- ----- - - ---- -- -- - -- ------------------------------ DATE--------�=`---�1�--- -- ----�J------�----------- � �-- t -•--- DATE--------------- ' BUILDING PERMIT ISSUED!II_________________ D BY .i -- Alterations and/or recommendations ___. ----------------------- D �E { :----- )_^ FINAL INSPECTION BY:. -------- ------------------------------------ ------ Date 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 1 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Trac California I y. E5-9-2M 10-52 Revised W-2100f