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APPLICATION FOR SANITATION PERMIT Permit No. ___----- __ (Complete in puplicate) �T' t Date Issued Applicaa-ion is hereby made to the San Joaquin Local Health District fo+r a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 544. JOB ADDRESS AND LOCATION... -. ______ ___ M . - Owner`s Name fN ------ -- --- = Phone = i. r., - - --- --------- ----------------------------------- ------------------------ n 'W/ �. ' Contractor's Name------=- r � Q Phonehl Installation will serve: I4Residence ❑r Apartment House ❑ Commercial Trailer Court ❑ Motel►❑ Other ❑ Number of living units: ___:____ ber of bedrooms --- ---- Number of baths---------- Lot size ______ ,, ____- ---------- Water Supply: `Public system` Community-system•❑ Private'❑`"Depth`+o`Water Table' -,.1-'tt:""I .. - Character of soil to a depth of 3 feet: •Sand ❑ :,Gravel ❑. Sandy Loam ❑ C .y--Loam❑G Clay ❑ :tAdobe . ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 4 (No septic tank'or cesspool permitted if public-sewer is available within 200 feet.) Septic Tank: Distance from" nearest we1L '""°x"'"_"�'Distance"from foundation___________________Material___:___:_______.__-____ No. of compartments----�t--`- ._--_*'.'-..-'Size--------------------- --•-- Liquid depth-------------- --- ------Capacity-- ------------------- T" --- ------------- �C; Dispo rlFti,d: Distance from nearest well_________________Distance from foundation----:_____:---------Distance to nearest lot line.-_..____________ -lumber.of lines-----------=---------- Length of each line----•-----------•------------------k---..Width of trench----------------=------------__-_-- ype'of'f er material______________________ pth of filter material------------------------Total length__t---.--------------------- :§---------- ---------- f ____ __ Seepa P Distance to neare�st we"ll_. �d__ Distance from fo ndation. "'"" ' � ...:____.Distance to nearest lot line__1_� t ❑� ` Number of pits---�,7 _s------Lining material_,__ _ ` �Y-r_.5ize: Diameter------ ,R---------Depth_-_'_�-�--�= _ - Cesspool: Distance.from nearest well_________________Distance from foundation_____-- __'_--.lining material---------------------------------- ❑ Size Diamete�rr-------------- --------------a; Depth--------I-------------_------=------------=----.--___YLiquid Capacity----------------------------gals. Privy: Distance from nearest well------------- --- -______________.________.___Distance from nearest building__'_______-__-- ___ -- ❑ bistance',to.nearest lot 'line- -=- , .wW u ----------- ------------------------------------------------ ---- - -------- Remodeling and/or repairing (describe):------------- - ------- -- ----•........ .. ............:... .------- --- - ---------- ---- - ..... ,-. - ------ --- - -- -------- --------------- I hereby certify that I have prepared this applicati and +hat the -will be done in accordance with San Joaquin County ordinances, State laws, a d rules and regulations of the San-Joa in Local Health Distri ) (signed] _ r "'- / rr --------- ! ---(O %an /or ctor) --•--- rT4 By: •`ate �-------- c - - - : -•-•--•------•---------(Ti#le}------� . .... - n{--a--------wno (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 t f APPLICATION ACCEPTED BY-------------------------- ------------------ ----------------------- DATE----------- 1 , '--------- REVIEWED BY--------------------- -------------------- -------- ----._ DATE----------- -_. BUILDING PERMIT ISSUED------------------------------------ ------ ------ - `------- - --- —__ DATE------------------------------------------------------------- Alt ti nd/or,recommendations:. == -- - �.----'-°-•-----------t- - •- ---- ------------------------------ -- = f u . _P` #1 _. ._ ---- ------- - ----------------------------------- -------------------------- -- ------------------------ -- - r ---------- ----------------------------------------------------------- -------•----------------._..------- -•---•-----------. --------------------------------------------- . ---------------------------------•--•---- I FINAL INSPECTION BY:._ .:.___f -=-----------= ------- r`r`......._.. - - Date------. --= -------------------------------------------------- SAN - - ... . ---... 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 _