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APPLICATION FOR SANITATION PERMIT Permit No, .w... .`-!� (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, JOB ADDRESS AND LOCATION_..._ _f -4� y' ----------------------------------•-----------••------------------------ Owner's Name--------- A ---------------------------------- ...L - - Phone.-_. Address ---------------------------------------------------------------------------•-------------------------- -- -- --•--- Contractor's Name----------• -• --- - ---------------------------- -- •-------- Phone--------- , Installation will serve: Residence [�Apartmenf House [ . Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ --.. Number of bedrooms ----__. s' - Number of baths __.____- Lot size _ -.- Water Supply: Pubfic system Community system ❑ Private ❑ Depth to Water Table __-. ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted-if public sewer is available within 200 feet.) a er a Septicfrom foundation--------------------Mtil an Distance from nearest well El No. of compartments------ -------------------Size------------- ----------------Liquid depth-------------- \ Cap Y- -------.-Ca acit - ----_A Disposal Field; Distance from nearest wei!.................Distance from foundation---------------------Distance to nearest lot line-----_..._-------1` ❑ Number of fines-------•--------------- ------Length of each line------------------------------Width of trench------------ ----- W ----------------- Ype of filter material-------------------------Depth of filter material-----------------------Total length--------------------------------- (� Seepage Pit: Distance to nearest well................:.....Distance from >I foundation__.....--_____•---.Distance to nearest lot line--. ❑ 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 nearest buifdin j Distance to nearest lot fine------------ ---- g ------ �� --------------------------------------------------- Remodeling and/or repairing (describe)------------------------------- ----------- ----------------------------------- --- .._------•"-`------_----`----`............................................•-----------_._....------------------•-•---`-....._.__..__-..._.__..-----------------------------------_-.._...---_.------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancesjS to laws, and rules and regulations of the San Joaquin Local.Health District. (Signed)---: - --- - ---- -------- ... '_ :r --- --- ----------------------------- •---- --------(Owner and/or Contractor) By:-------------------------•-------------•----------------------------------- ----------------------------------------------- - - - Title __ - (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...:._.._____._____________________-__ �� DATE ,2- `-. REVIEWED BY ------------------------------- ----------------- DATE BUILDING PERMIT ISSUED --------------------------------------- --------------------- ------------------------------------------- -- -------------•----------- ---- DATE ------------- ----------- 4Alterations and/or recommendations:---------------- -- 4 ......................................................................:..................................................................................................... ........... i ..............................._--.-----.....:-. ....._.------------------------------.-----------..-----------.-.---------------------.----------.-------------- ` ..... -...-.....- ................. ................... FINAL INSPECTION BY----------------- •�1 'C- -------------=-- Date..-.----------- . � �)� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M f0-52 Revised W-2100