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APPLICATION FOR SANITATION PERMIT Permit No. ____.-------- _... (Complete in Duplicate) Date Issued -__ � f Applica{ion 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 JOBADDRESS AN i ----------------------------------- ------------------ --------- ------------------------ ;CC Phone-Owner's Nam .4 - - - -------------------------------------- ---------------------- ------------------------: - - . ' - Contractor's Name------ - Phone. ��AddressM+ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/--- Number of bedrooms __. Number of baths --/__- Lot size �----- Water Supply: Publics stemCommunitY system ❑ - Private ❑ De 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)9— New Construction: Yesx No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `�. eptar Tank: Distance from nearest well________________Distance from foundation--------------------Material___________:.__.______.__._.__________.-._.-____. No, of compartments-------------------- ----Size--------------------------------Liquid depth-----------------------.---Capacity------------ Dispo k'Field: Distance from nearest wel!-----------------Distance from foundation--------------------Distance to nearest lot line................. I f lines---------------- ------------------Len Length of each line------------------------------Width of trench------------------------------- Number o g ---- Type of filter material------------------_------Depth of filter material-----------------------Total length-------------------------------- Seepa e Pit: Distancb to nearest.well_�r------Dista nce orn f ndation_..�d.'__._..Dista�ie to nearest lot line_ _�__�------- Number of pits---- _-------------Lining materia ----Size: Diameter___. �-._______..Depth------ _________.. Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material____.._.________________.________.._ > ❑, Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Tom' 4 c Privy: Distance from nearest well--------------------------------------------------Distance from nearest buildIng------------------------------------------ ❑ Distance to nearest lot line------ ------- ----------------------------------e--------------------------------------------------------------------------------------- - f r Remodeling and/or repairing {describe):--- -- J = ------- `" -------------•-------------------------=------------------------------ -------------------- ------------- - 1 ---------------------------------- ------------------------------------------------------------------------------------------------------- I hereby certify that-I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stake laws, and,,rules and regulations of the San Joaquin Local Health District. [Signed) A`----- ------ ------ ----- ------ ------------------- Owner and/or Contractor)-" B / (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pl d o� averse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- r - --------------------------•--------------------- DATE---------- � REVIEWED BY------------------------------------------------------- ------------ ---------- ---------------------------------------------- DATE-------------------- ---------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------ ----------------------------- DATE--------------------------•---------------------------------- Alterationsand/or recommendations:-------------- -- •- ----------------•-••----------......-----------------------------------•----------.-_-------------------------------._.. ---- }I---------------- . ------------- ---- --• -- - ---------- --------------------------•- - ------4. 1--- -------- ---•-•-------------------------------- ------------------ ----------------- -----------•---- -- --------�-------------------------------------------- - --- ------ --------- ----------------...----------- ------------------------------------------------------ --- -- -- ----- :: :.---- v r FINALINSPECTION BY:—.-/ -'-'- ------------------------ -----•----- Date. ------------- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California t cc o_4AA P.,;-4 w_910n