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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 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 it County Ord' nce No. 549. JOB ADDRESS L A� fp I-- ------- +1 `... ------- ---------------------- ----------- Phone-- -- -------- 'II c� f Owner's Name y " ---•------------------------------------------- eJ U�-,71./ Address----� � — ----- —II -..---•----------------------•-•----------------------------------------------- Contractor's Name--- ---------•---------------- II„- ------------------------ Phone---•-----•------•-•-------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._/---- Number pf bedrooms ---/--. Number of baths _I... Lot size _____________________ Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table -------- ft_ Character of soil to a depth of 3 feet: Sand]❑ Gravel ❑ Sandy Lo2PNO Clay Loam E] Clay E] 'Adobe �ardpan ❑ Previous Application Made: Yes E] No New Construction:. Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS. (No septic tank or cesspool permitted hf pp�ublic se er is available within 200 fee}et..) ,,J Septic ank: Distance from nearest wellL u- Dista cue fr foundation��l-_r-- Mater' }____._6___-_--1 No. of compartments------0---/�---------- S'z _x - ------L'quid�depth---------�---------.Capacity--- -Q--- Dis osa Field: Distance from nearest w�II'. _ .Distance from foundation/0Distance to nearest lot.I+ Number of lines____________ _ �� ____.__-_ _Length of each line--------------- _______- --6 Width of trench.__._ _.____ g ff-- /------------------ Type of filter materi __, _ Depth of filter material----------t- ----------Total length---_------- _______________________ 1 Seepage Pit: Distance to nearest well_h-------------------Distance from. foundation--------------------Distance to nearest lot line____---- -------- ❑ Number of pits-----------------0---Lining material-----------------------Size: Diameter-----------------------Depth-----------------------_._.__---_ Cesspool: Distance from nearest wall__________ ___Distance from foundation-----__.-___-___ -.Lining material______.-.---------------------------- ❑ Size: Diameter----------------- ------------------Depth-------•-----------••--•----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building------------------------------------------ El Distance to nearest of lid�e-------------------------------------------------- -•------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe) �'' ------- ------------------------------••-•------•---------=------------------------------------------------------------------------------ I�---------------`--------- ------------------------------------------------------------------------------------------- ------------gip -------------------••----- --------------------------------------------------------------------ll ------------------- ------------------------------------------------------ ...._.-------------------------------- ----------------------------------- --------------------------------------- --------------------------- -----------.------------------------------------------------------------------------------------------------- I hereby certify that have pr pare. this ap 1ic tiara and that the work will be done in accordance with San Joaquin County ordinances, 5 laws, n e nd ulation o the San Joaquin Local Health District. (Signed) -- ----_-/- -- --- --------------------------------------------------------------------- -----(Owner and/or Contractor) By:----------------••---------------------------------------- - --------------------------------(Title)------------------ ----------------------- ----------------- (Plo+ plan, showing size of lot, location of sy gem�in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1[--------------------------------- ---------------------------------------- DATE - ----- ---- --- REVIEWED BY---------------------------- q DATE-- -- BUILDINGPERMIT ISSUED---------------------- ----------------------------------------------------------------------- DATE..---- ------------------------------------•-------•----- Aiterationsand/or recommendations--- ----------�p -----------------------------•-------- ------------------------...------------------------------•---•-------------------------- --------------------------------------------------------------------------- ---------------------------------------------------------------•----------------------------------------•---....----•-••--------•--------------- -------•-• ---•-------------------------------------- --------------------��--------------------------•----------------------------------------------------------------- ------------------------- -----------••-----•---------------------------••-------•---•---------- -- ---------------------------------•---------------------------------------------------------------------------- ----------:--------------------- ---------------------------------------------------------------------- p----------------------------------------------•--------------------------------- FINAL INSPECTION BY:-------- � Date_- ------ ---- -----� � SAWN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California LOtlI, California Manteca, California Tracy, California ES-9--2M 10-52 Revised W-2100