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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.- --------------�e �'�` G------------------------ ---------------------------- -------- JOB ADDRESS AND LOCATION-------• - �� r Phone NR -----T ' Owners Name-------------------- •---------- Address----_------- --------Address-----•---------•---------------=� -------•-- o- -------------------------- - _ _ _ =------ `---------------------- Ph one Contractor's Name______________________ - Installation will serve: Residence [] Apartment House ❑ Commercial ❑ Trailer Court 9 Motel ❑ Other ❑ Number of living units: _/_ Number of bedrooms -------- Number of baths _______ Lot size --------- Water Supply:_ Public system Community system C] Private El Depth to Water Table -------- ft. Character of soil to a depth of 3 feet:¢;Sand ❑ Gravel F1 Sandy Loam [I Clay Loam El Clay E] Adobe[ Hardpan ❑�► Previous Application Made: Yes No ❑ New Construction: Yes,❑ No El TYPE OF INSTALLATION AND SPECIFICATIONS: R feet.)' � {No septic tank or cesspool permitted if public sewer is available within 200 fee+ Septic Tank: Distance from nearer} well__ - Distance from foundation'Z_�------------Matenal_ ---------------- - -�---- No. of compartments_ ---------Size---- Liquid depth------ 07t3---- Capacity I,n A sx C',-3r• r ---- Di o al Field: Distance from nearest well__�cn"'�•.-_Distance from foundation_____—S-_______.Distance to nearest I- line . --0.............Width of trench - -------- Number of lines______________ ------------- Length of each line----------------- � ,� Type of filter material----- of filter� er a l-------1$---------Total leng+h------------- �- 4------------- Seepage Pit: Distance to nearest ell__ Uy"�^_--Distan rom Vfn____. 5-_- Dance to nearest lot line____Number of pits . = Lining mat tai- --------- Diameter_34_F-----------Depth 2'`45Cesspool: Distance from Bare"si"we1l--------.--_----Dis n--------------------Linrng material---------------------------------- ❑ Size: Diameter-------------------------------------- Dep+h- ----- -------------------------------------- Liquid Capacity gals. ' Privy: Distance from nearest well------------------------------------------------Dis#ants from nearest building---------------- ---------- ---------- ❑ Distance to nearest lot line------------------------------------- --------- ----------------------- ----------- ------ -------------------- Remodeling and/or repairing (describe)------------------------------------------------------------ - -----------------------• ------------------------------------- -----w-----•----------•------------------------------------------------------------------- ----------------------------------------------- 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 ans� regulatio 's7 of �Soaquln Local Health District. ------ -----------------------(Owner and/or Contractor) (Signed)---'- -_ -veils --- ----- --- ------ ----- Title ' (Plot p n, showing size of lot, ocatton of system m relation to , buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ --------- -- --- DATE------------- 7- REVIEWED BY------ -- - ------------ - -f-,, '' BUILDING PERMIT ISSUED DATE --- - _ ---�--- ---- DATE------------ - -�---- --� ---�- Alterations and/or recommendations:__________________-_.._-. (/ - -- --------- ----- ------------ - -----------------------------•-------------------------- ------------------------------------ FINAL INSPECTION BY r_-_--�- ------------ Date------ F ---------------------------•-------- SAN JOAQUIN LOCAL HEALTH DISTRICT ` 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street TracCalifornia Stockton, California Lodi, California Manteca, California Y• ES-9-2M 8-51 Revised W-2100: