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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 ' County Ordinance No. 549. + --- ------ JOS ADDRESS AND LOCATION.---__ _--!/'' -- � -' -- - ------ ------------ - - --- Owner s Name---- f Address f (----------------------------------------------------- --- --------- - Phone-------- -------------------------- Contractor's Name-------------------------------- P Motel ❑)0. Other [I Installation will serve: Residence A artm •t House ��C mmerual ❑ Trailer Court ❑ ,j Number of living units: ._ Number of bedrooms .=1'__ Number of baths -1----- Lot size -----------------------•--- ---------------------------- Wafer Supply: Public system ❑ Community system ❑ Private Depth to Water Table ..r0-. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[K Hardpan ❑ Previous Application Made: Yes E] No New Construction: Yes No E]TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if plic sewer wer is available within 200 feet.) Septic Tank: Distance from nearest well...._". _"...Distan eNfrom fofdatio �___-Mat eyia4"...... " :" --- -------------- ] No. of compartmenfs"--___.-- Size._ " .�=5-- - - -Liquid de fh_"..----i4'=-:-----""__-- Capacity_ ------- - Disposal Field: Distance from nearest well--Z-0------ from foundation. _d---------Distance to nearest lot Number of lines-------- --------- ------------Length of each line. +--.-- "Width of trench---- ---- Type of filter material..- _Depth of filter material--__/- -------------Total length ---- ------------------------ `. Seepage Pit: Distance to nearest well----------------------Distance material from foundation Diameter_--_Distance-toDn�p�est lot line-=-=----------- � 1 Cesspool: Distance from nearest well-------------.-.-Distance from foundation--------------------Lining material-------..._.-..---.-..__".._- --- ❑ Si -------Depth----------------------------------------------------Liquid Capacity------------------ --------gals. Size: Diameter------------------ ------- T Privy: Distance from nearest well------------------------ ------------Distance from nearest building---------------------------------------- ❑ lot line-------------------------- ------------------...-.-------------------"----------------------------------------- --------------- ------------- Distance to nearest . �, ----""Gw-- "'""' --------------------------------------- Remodeling and/or repairing (describe]:...� -- ---"------'"----�'" - .------- - ----------------------------------------------------- ----------------------------------- -------------------------------------•- ------------I---------------------------------------- ----------------------------- --------------------------------- ----- ou ... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C ordinances, State laws, and rules and regulations.of the San Joaquin Local Health District. (Owner and/or Contractor) By:. - ---(Title)-----------------------•-------------------------------- ------- - ---------------------------- - - -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------•------- ------------------------------------------------ --------------------------------- DATE--------- --------- ------------------------- REVIEWED BY------------------------------------- - DATE DATE -- _ --------- -"-----------�--------------------------------- BUILDING PERMIT ISSUED--------------------------------------------- Alterations and/or recommendations:------ -----------------------•-------------•------------------------------------------------------ -------------------- -•---•-----"-----------•-----------••----------------------------------- - ----.rzc.e� 1 [ r ----•-------------------------------------- ----- ---- ------------------------------- ------ --- ------------ -_- A _ FINAL INSPECTION BY---------- -------- - 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-9-2M 10-52'Revised W-2100