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APPLICATION FOR SANITATION PERMIT Permit .3 ermrt No�.__..___ (Complete in Duplicate) Date Issued ----------------------- Application ---------""-•-- "-Application is hereby made to the San Joaquin Local Health District for a permit to construct install the work herein described. This application is made in compliance with County Ordinance No. 549, �G�U�l77yC ST L JOB ADDRESS AN O TION_ __-- -- --"- ------- - 'ted ------------- ---C1t),-------�---- -• ---------- --- Owner's Name °_ .__ - 11 -- ---- -------------------------------- Phone ----------- ------------ Address f ----- -�-- -- ----- ---------- ----- -- Contractor's Name______________ _,- Installation will serve: Residence>4apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other Number of living units: __�___ Number of bedrooms -_-+�--- Number of baths j... Lot size _____ El Water Supply: Public system ❑ Community system ❑ Private 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 ON New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic TA: Distance from nearest well-----------------Distance from foundation__________________.material ___________.._._ o. of compartments Size ------------Liquid de th----:.---------------------Capacity------------- Disp sal Field: ;stance from nearest wellp! U _`listance from foundation__ 1 _. _.Distance to neares of lei -___r_ umber of lines-------- ___ . Length of each line____ ^, R,,,, Type of filter material "- - Width of trench__-__f____ - "�_-_..--"-_""•""- 1�Iti Depth of filter material_._.- -- _Total length------ C Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line_____._____.-- ❑ Number of pits----------------------Lining materia l----------_� ,-----Size: Diameter--- •------------------Depth------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------- --El ------- material___._-""--"""""_--_""_-- Size: Diameter------ -------- --------------------Depth------------------------------------ ---------------Liquid Capacity--------------------- ----__- ---gals, .: - - { Privy: Distance from nearest well_______-_____________________-------------_______._Distance from nearest building__________--------------------- �(,a ( Distance to nearest lot line _`___._. --------------------------------------- Re 6deling-&nd/o ;ring (describe,: I . ------------- "is application and that the work will be done ineccordancewith San Joaquin Count ordinances, State law/s, and rules an regulations of the San Joaquin Local Health District. y I hereby certify drat I have prepared e� _ 4 (Signed) Y � ------------------------------------------ (Owner and/or Contractors � BY= -------- ----- -- -- Title ' g p --- --------------------------------------- - --------------- P of plan, showing size of lot, location of system in relation to wells buildings, efc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------- ----------------------------------------------------------------- DATE REVIEWED BY_ - . DATE_-- - UILDING PERMIT ISSUED f ----------------------- --- ---------- DATE- - ----------------------• - Alterations and/or recommendations:--______...___-"-"" ---•------------------ 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