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APPLICATION F OR SANITATION PERMIT Permit No.�..�.�.- (Complete in Duplicate) pp / Date Issued Q.._ Application is hereby made to the San aquin Local Health District fora permit o construct and install the work herein described. This application is made in compliance with County Ordinance-Vo. 549. JOB ADDRESS AND ATION---.------- ------ _ --------------------------------------------- Owner's Namer • - 1) Phone. - -- Address -------------------•---------------------------------- Contractor`s Name - ----- - - ------•-------- ---------.Phone----- Installation will serve: Residence Apartment House ❑ ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ --- umber of bedrooms "g& Number of baths .-/-. Lot size ..' Water Supply: Public system Community system ❑ Private ❑' Depth to Water Tal�lft. Character of soil to a depth of 3 feet: Sand ❑ GraJel ❑ Sandy Loam ❑ Clay .Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPEC FII CATIO N5. (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 --- ------------------------ Disposal ------------------ ---Disposal Field:/ Distance from nearest well ----------------Distance from foundation....................Distance to nearest lot line_._.-------...... � Number of lines -- -------------- ---Length of each line------------------------------Width of french--------- r l (// Type of filter material-------------------------Depth of filter material-----------------------Total length-------------- --------,------------------- Seepage ------------ w I ------ See a e Pit: Distance to nearest ell- P g .Distance f m fo dafion.... ._--___.Dista ce to nearest lot line-..... .......... Number of pits------ .-_.......Lining material - - .Size: Diameter---- C --. . Depth..-_.__-....�� Cesspool: Distance from nearest well-,...............Distance from ------ - material-...-._....._..___-.-..-.._-..._ _- ❑ Size: Diameter--------------------------- ----------Depth----------------------------------------- -.--------Liquid Capacity- --------------------------gals. Privy: Distance from _ nearest well..-.- ------------------------------------------Distance from nearest b0dg ----in t r ---------------------------- ❑ Distance to nearest lot line---------- --------- -------------------------------- 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 ordinances, State la s, and r e d regulatio of the San Joaquin Local Health District. (Signed) r '- -------- -- - �-- ----------- (Owner and or ontractor) By:--------------_-- -- ---f------- - ------ -------------------------------- (Title)-- � -�. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla on reverse side). FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ ------- -- - ,------_- ------ DATE REVIEWED 8Y -- - ----- ----- -------------------- - --------------------- --- DATE BUILDING PERMIT ISSUED :.-. DATE. ------------------------••---------- Alterations and/or recommendations:.............._.-.......- ---------------•--------------------------------------------------------------- -- ---------------------- -- --------------------- --------------------------------------------------------------------------------------•---------------------------------- --------------------------------------------- ---------------------------------------------------------------------------------------•------------------------ FINAL INSPECTION BY:..... --- Date--------- r 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 10.52 Revised W=2100