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APPLICATION FOR SANITATION PERMIT Permit N,---6....._.. (Complete in Duplicate) s' Date Issued- -.----_- .�3 Application is hereby made to the San Joaquin Local Health District foraper it to construct and install the work her in describ This application is made in compliance with C unty Ordinance No. 549 „ VJOB ADDRESS AND LOCA ---------------- --- -- -- ------ --------- ----- / -- - Owner's Name-- ---- - ----- = ""-'�----- --------------------------------------- Phone___-r Address----- �, --------- -- --------- Contractor's Name l� Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer' Court ❑ Motel ❑ Ot er ❑ Number of living units: _f--__ Number of bedrooms/--.- Number of baths .49-- Lot sizer _______ Water Supply: Public system ❑ Community system ❑ Private,�VDepth to Water Table_ _- ft. IE Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobA Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes E] -No TYPE OF INSTALLATION AND SPECIFICA IONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ti,ptic Tank: Distance from nearest well-----------------Distance from foundation_________________.Material_______-___--__.__--_-_________-_._...---------- } No. of compartments� P ------- ----Size--------------------------------Liquid depth--------------------------Capacity--------------- ------- Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line______..-___---_. ❑ Number of iines-----------------------------------Length of each line-----------------------------.Width of trench------------------------------:---- IFType or filter material-___--- _,_____-__-Depth of filter material-----------------------Total length__________________________________________ t Seepage Pit: Distance to nearest well_�� _ -____.Distance f m fou ation_ ...........____.Dislance to nearest lot line--- -------- lumber __- x Number of pits.__-I-__--_.__.__Lining material _ _ ________ ____Size: Diameter___-.-_..__---__-Depth_.._,��_�___------ --- I esspool- Distance from nearest well-----------------Distance from foundation---.----------------Lining material------.---__------_-------____.______ ❑ Size: Diameter------------------------------------ Depth----------------------------- -------- ------- -----Liquid Capacity---------------------------gals. Privy: Distance from nearest well ___.______________-----------------------------Distance from nearest building--------------------------------_.------- ❑ Distance to nearest lot line--------- -------------- --- -------- ------------------ ----------- ---- oe Remodeling and/o repairing (describe):---____-- .w- _r ---- -- _ --- ------------------- 5 --------------- __ __________ ------------r _ _____-____ ______.__ --------------__-________ - _-_-___-___________________._.________---_.________.-_______..--_-_--_-__..____-___-__--__-.-.._ ------------------------ --- - --- ---- --- --- ----- ...................----------- ---------------------------- - --------------------------------- -------•---------- ---------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------ 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, rules d r guI ions of th n Joaquin Local Health District. __ -- Owner and or Contractor (Signed).__.. - -- { / I BY: - --_----- :-----------------------------------------------------------(Title)-,.— __1 (Title - - ----- (Plot plan, showing size of lot, ITpc ion�o`f system in relation to wells, buildings, etc., can be plc on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- DATE*--------------------------------------------------- -------- ----------------------------------------------------------------- - REVIEWED BY DATE r ------ � - I BUILDING PERMIT ISSUED-------------------------------------------------------------- --------------------------------------- DATE------ ----------- --- Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------------------------- •-------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ------•-------------------------------- -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL --------FINAL INSPECTION BY...".16 ----- 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.`4-2M io-sz Revised W-2100