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APPLICATION FOR SANITATION PERMIT Permit No. -------------�------ (Complete in Duplicate) Date Issued + -` Applica+ion is hereby made to the San Joaquin Loca4 Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. QQ�� Ute' `�"' f�('C�% !�7f. ------------ ---- -- JOB ADDRESS AND OCATION...___ --- ""A" Phone-------- --------------------- 4_ ....� - Owner's Name._d , ---------------------- - --- Address r � c 't --------•- --•---------•------------ -------------------•---------------------------- ----- -•------------------•----------- f ---- --- ---- Phone----------------------------------- Contractor's Name--------- - - - - ------ --- Installation will serve: Residence Apartmen ouse ❑ Commercial E] Trailer Court E3M el IJ Other ❑ Number of living units: Number of bedrooms _Number of baths --- Lot size _-._ Water Supply: Public system ❑ Community system ❑ Private e Depth to Water Table 7 ft. _ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam L] Clay ❑ Adobe C] Hardpan [IPrevious Application Made: Yes [3 No A.New Construction: Yes,& ' No [:1TYPE OF INSTALLATION AND SPECIFICATIONS: ? (No septic tank or cesspool permitted if public sewer is available within 200 f --- -- -- SepticYTarik:�'°�`"Distance'fro Distanc from founds ion �____ Mater�a__- Li p, -Capacity-- 4 No. of compartments"-- Size__ ""�Q-- - - quid de th----------- ------- -- /�' /y Disposal Field: Qistance from nearest well---- Distance from foundation______ _ .__.Distance to nearest lot line Number of lines________- _-._-. /.".---Length of each line---------/.; - ,. Width of trench " l- L� Type ------------ Number filter material___ - . Depth of filter-material___.____-- --- ----Total length___________ -.0---------------- Seepage Pit: Distance to nearest wel __.-.__-__".___._.-Distance from foundation___________________Distance to nearest lot line____________.-___ ❑ ..Size: Diameter----•----------- Depth-------------------------------- Number of pits----------------------Lining material------.----------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------_"__.Lining material ❑ _ .. — .,,�. - . material__._-.-.-. _________-_.______.___-_____ Depth , T _ Liquid Capacity : : -- - Size: Diameter--- ---- -- ,�--= Privy: Distance from nearest weDistance from neatest building ll-------------------------------- ❑ Distance to nearest lot line--------- ------------- -----•".---- ------- -...--------- ---------------------------------------------- ------------------------ ----------- - Remodeling and/or repairing (describe)--------------------------------- -------- ------••------•----- ------•-------••-----------------•-------•----------------•----•-•-•-------.-.----•.------ -- ------ ------------- - - -------- ---------------------------------------- -----------------•------•---- -------•------•---------------•------------•----------------------- I here- by certi-fy that I have prepared this application and that the work will be done in accordance with San Joaquin County z ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ----------------- ------(Owner and/or Contractor) (Signed) . --- ------ -- - -- tl (Plot plan, showing size of lot, location of system in Tela+ion to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY DATE---- ------------" --- --- - --- APPLICATIONACCEPTED BY----------------- ---------- ---- --- - ----------------------------------- REVIEWED BY------------------------- .. ' - DATE------ � - w --- ----------------- BUILDING PERMIT ISSUED------------------------------ V------------------------- ------ DATE---------------•------------------------•------------------- r ---------------- r--- ---- - ------------------•------------ Alterations and/or recommendations:-------------------------- ----------------------------------------------------- ----- - ------------------ ---------------- -------- - -------------------------------- - -------- Date--------- Z-- -- ------------ FINAL INSPECTION BY_____________ _ __ __ ""` SAN -1OAQUIN LOCAL HEALTH DISTRICT l3o 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 lasaas nrwnoo lz-sa _ -