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APPLICATION FOR SANITATION PERMIT Permit No. .st ..... (Complete in Duplicate) Date Issued Applica4ion is hereby made to the San Joaquin Local Health District for a � q permit to construct and install thew rk herg d scribed. This application is made in complian a with County , rdinance N 549. JOB ADDRESS AND L ATIQN__ __ - -__--_- " � Y � I -- -- -- ----- ------ 'Owner s Name Phone Address �------ ---- ------- g �- . . Contractor's Name t � - - --------•-- - - Phone = Z Installation will serve: Residence Apartment House ❑ Commercial railer Court ❑ tel ❑ Other ❑ Number of living units: -I-___ Number of bedrooms 4--- Number of the Lot size ------ -----•-- - -- -•- -------•--------------- Water Supply: Public system E] Community system El Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes Ur No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � Septic Tanks Distance from nearest we ._ _---_ is aterial--_____________________________________________• No. of compartments r -------------- ---------- Liquid depth--------------------------Capacity ... Dispose, Distance from neare t well/4-if-------Distance from foundation-- __�_�-- Distance to nearest lot line-Z--a. ' Number of lines- _------- ength of each line-_ !�EWidth of trench.___ Type of filter material__ �� ^/ -----------------•-- yp _„Depth of filter material---..� ----------Total length---._-_-- ------------------ --•-� Seepage Pit: Distance to nearest well--------------- Distance from foundation_-_..-----------_-_Distance to nearest lot line---- _-_.--_...--_ � ❑ Number of pits---------------------Lining material------------------------Size: Diameter-----------------------Depth---------------------------------- Cesspool: Distance from nearest well_---------------Distance from foundation--------------------Lining materiaL_._-_-------------------------._---_ 1'� ❑: -.: ,- Size.: Diamefer----------------- ---------------Depth------=------------:... -.=._r=-Liquid Capacity-------=- =^� =- -9®Is. �•}*de Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--_--- ------------------------El Distance to nearest lot line.----- ------------ -------- --------- --------------------------------- Remodeling -------------------------------- r Remodeling and/or repairing (describe):----_-- --------------- ------------------------ --------------- r ------------------------•--•---------------------------------- -------•------------ --------- a- -=_--------------------------------•---..-------------------------------------- +� -----------------------------.------------------------- ---- - ------- —i --------------------------------------------------------------------- I hereby certify that I Neve prepared this application and' the work will be done in accordance with San Joaquin County S ordinances, State ws, and rules and re lation} of +he San aquin Local Health 'strict, (Signed)•---- - --• Id- -- -.___W--- ----- -- ------ -- -- -- ---- Ow r and/or ontractorJ 3 SY• r e (Title) (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse si e). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY .. -_: ;; :_A ___ DATE_— _.:---/��( i�_r�-r•--_ --- -=�-- `12171E1/�FD --- -- {__. - ---------------------------------------------- DATE----- --------------- - ------------------------------ BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------- --------------------------- A aerations and/or recommendations:--------------------------------------------------------------------- ---------•------------ ------------------------------ ---------------------------------------------------------------••--•--•------------------------------------------------ ------------------------------------------ ------------------------------------------...-----------•-=------------------------------------------------------ --------------------------- -------------------------------- ------------ --------------------------------- FINAL INSPECTION BY------------- r'� -------•-'-`:='_,-'- -- --- -------------•------- Date---------------•-------- ----------- •- --------•---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreof 300 West Oak Street 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES----9-2M ; Revised W-2100