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APPLICATION FOR SANITATION PERMIT Permit No. .___ _ '" (Complete in Duplicate) Co Date Issued ' 3- 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. -0 i JOB DDRESS AND LOCATION------------------------- 4 Owner's Name--------- Phone - Address----------- __..__T__ Contractor's Name ----------------------------------------------------------••-------- Phone---------------------------------- A. - _1j will serve: Residence ❑ Apartme House ❑ Commercial ❑ ' Trailer Court ❑ Motel ❑ ' 0111, fh r w Number of living units _______ Number of bedrooms --------- Number of baths ________ Lot size -------5-_-Qom..____- ____________________ Water Supply: Public system ❑ Community system ❑ Private [ Depth to Water Table :_______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lroam ❑ ClayLoam-El Clay ❑ Adobe[.Hardpan ❑ Previous Application Made: ,Yes ❑ No 4 New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within-200 feet.)---- "Septic eet.), ---Septic Tank: _Distance from nearest well-----------------Distance from foundation--------------------Material __-__________-____ _._._______ . ❑ No. of compartments--=------------------- -Size--------------------------------Liquid depth--------------------------Capacity--------------------- Disposal Field: Distance from nearest well------___-----Distance from foundation--------------------Distance to nearest lot line._______________== Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------------- Type of filter material-------------------------De fh of filter material-----------------------Total length_----------------------------------------�_ age Pit: Distance to nearest wel!_.__zo_ - stance from foundation__AQ_d__._-_Distance to nearest lot line-_� __r�___j" Number of pits-------_-I-----------Lining material---7�1. -R�C/gaie.n• er---- -------------- D th -- ------ -------------------� Cesspool- Distance from nearest well-_______-_______Distance from f�; _ __Linin r �.- -- _.___--- r _,❑-.,, . y Size: D:iameter� = : Depth v 4 Liquid d CapacitY�_ x;:� -=^.,--gaJ Privy: Distance from nearest well_--_________________________________-----------Distance*from nearest building ❑ Distance to nearest lot line------------------------------------•--------- Remodeling find/ r repairing (*scribe ;,- � .. --•-------Gni-I�,---- - -------- ` --��------ -- - --- -------- ----- •------- -- --------"--------- -- - - - - ----•-• ------•------------ - - ------ ------ - . __- - -- - ---------------- --- �r.�of _ _ __- - -4LA 4Z,9. ---------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ounty ordinances, State laws, and rules and r gulafions of the San oaquin Local Health District. 1 T��(Signed)---------•---- ---�••-- -- ------- --- - --- --- ------------------------ ----------------------------- ------------------(Owner and/or Contractor) BY: ------------••------------•-•------- -•-------------.---•-- ------•------------------------------(Title)= -------=---T-------= ------ a (Plot plan, showing size of lot, locetion�of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------ ---- ---- -- - ------------------------------------- DATE------------- 3REVIEWED BY ---------------------------- DATE-------- b 4: BUILDING PERMIT ISSUED =- -------------------------- --------------------------------- --------- DATE. Alterations and/or recommend 'ons:_______-_--__________ -__-____ ---- --- _ -- - �---�� : . -- ----------- - - . ., -- ---- ---- - - ---------- - -- _ FINAL INSPECTION BY:........ -------------•- --• .- --:----- Date_ �-- ' 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 10-52 Revised W-2100 I