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APPLICATION FOR SANITATION PERMIT Permit No. .__�.�____- API'LIC _ (Complete in Duplicate) Date Issued,__ `" /3-5 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. ---- ------------•---------------------------------- ----------------- •------------'----•--- JOB ADDRESS AN LOCATION_...___.? one Owner's Nam --- ---- -------------- -------- PhP Add�ess._ _.. r/t ------------------------------•-- •------------------------------------------------------- ----------- Contractor's Name------------ - --- -• ---• -- ��-------- - •��.--•-- ---------- - -- ------------- Phone--------"--:7/2� Installation will serve: Residence' Apartme f Ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ------------------------- `Number of living units: __./_ Number of bedrooms ______ _ Number of baths -�___ Lot size __ ________ __ ___ Water. Supply: Public system Community system ❑ Private ❑ Depth to Water Table/-1-:44fft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ElClay Loam ❑ Clay ❑ Adob4-,,-`Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ' .No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------ .---------Distance from foundation--------------------Material----_------------------------------.-_.___.______- No. of compartments_ ---size--------------------------- ---Liquid depth--------------------------Capacity---------------- ...... sal Fi� Distance from nearest well:._.___----_____.Distance from foundation Number to nearest lot line_________________ p Number of lines----------------------------------Length of each line-------------------- -------W�dth of trent -------- ------------- -------- O{�� Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ eeRe it: Distance to nearest well,, ��I ---Distance f, m fouAation eiameter ---------Distance to nearest lot line_-_y__-�.,Ai .: ......4) Number of p ----------- material_ a `' ' ��---Size: ______ _____________Depth--.. .h=-------.-----} ` Cesspool: Distance from nearest well_________________Distance from foundation--.._._._------___..Lining material_____.________.---_._______-_________. ❑; Size: Diameter-------------------------------------- Depth--------------------------------------------------- ----- ----------------------------------- ------------ Liquid Capacity gals. _____Distance from nearest building__________________________________________ I Priv Distance from nearest well-____--------------------------------------- ------ ________________________ _ ry --- ----- ------- f ❑ _ - Distance to nearest Iot'line__----' �: _ , - ---: ---- r -------------------- m V \ 00, Remodelin wand'/6r repairing (describe):__._ _ �Y ---- - ------•------- ----------------------- /rdinances ------------------------------------------•---------•----------------------------------------.---------------- ---•-----------------------------•---------------------- ------- ---- ------- - ---- -- --------------------------- -------- ------------- ----------------------------------------------- - eby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County , 5t laws, and. ru s and .e u a,ions of the San Joaquin Local Health District. f (Signed}... --``•�-- �" � ------------- ------- (Owner and/off„ Contractor} ` t ,/ Tale - ----------- By=----------------------- ---------- - --- ---K-&----- -------- ( � } (Plot plan, showing size of to , ocation aystem in relation to wells, buildings, etc., can be pl on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---._ DATE -------- -------------------------------------- ------- -----------------------------• DATE---- REVIEWEDBY------------------------- ----- - �-----------------------------•--------- BUILDING PERMIT ISSUED •----- ---------------- DATE------ �\-------------------------------------------- i - ------------------------ Alterations and/or recommendations:_______._____--_.._ ------------------------- ----- ---------------------------- --------------------------------- --- -------------------------------- --------------------- - J FINAL INSPECTION BY---- ----- - ---- -- -------------------------- Date U -------------- 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 4 ES-9-2M ; Revised W-2100