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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issue Applica4-ion is hereby"made to,the San Joaquin Local Health District for a permit to construct and install the work herein described. This application.isrmade,in compliance,wifh County Ordinance NQ. 549. JOBADDRESS AND LOCATION._ _ 7_. -=-----------------------------------•-•------------------------------------------------- --------------------- Owner's Name_ Phone------------------------------------ �. Address------------- ------- ----------------------------------------------------....------------------------------------•-•---•---------------------------------------------------- --------------- Phone----------------------------------- Contractor's Name-----=--------------------- ----------------------------------------------------------------------------------- t ' Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�.__-_ N ber of bedrooms dumber of baths _�____ Lot size _��_Q__�-__'��--------------------_------- Wafer Supply: Public system" k Community system ❑ Private ❑ Depth to Water Table.��__ ft. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam El Clay Loam E] Clay ❑ Adobe lardpan ❑ Previous Application Made: Yes ❑ _No [ New Constructio Yes E---No ❑ 'TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public se W r is available within 200 feet.) W__ y jrr Septic Tank: Distance from. nearest well -_.._.__ ___Distance from foun anon_r�_______________ aferial__ ___ _________._.. ____-_ _ No. of compartments___ Size__ y --=___Liquid depth__�_S_Vc__-____Capacity___ �_�____ Disposal Field: Distance from nearest well ---.________ Disfance from foundation__1. -_.__._.Distance to nearest lot line_________________ (*„ i W Number of lines---oto-- ---------------------Length of each line------------------------------Width of trench-___ --- ------------------------ Type of filter materi _______________________-Depth of filter material. T*Notal length--- IN _ _.U______.___________ See a e Pit: Distance�to ne w p g ares , ________________ Distance from foundation----....------------Distance to nearest lot line_____.-.__.____.. ❑ 'Number of pits---'--------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- p M1P t -----.Lining material------------------------------------- Cesspool: Distance fi�om{nearest wef!_________________Distance from foundation===:-:�---.--- Liquid Capacity_-__._-_____________________gals. ti Size: Diameter----------- _ De th____ Privy:} Distance_fr m nearest well--------------------------------------------------Distance from nearest_building-f__...________________..____._____------ ❑ "Distance to nearest lot line-------"-- :------- -` -------------- ---------------- Remodeling and/or repairing' (destnibe):----------------------------I----------------------------------------------------------- k i :.'- -----------------------------------------------------------------------------------------------•------- 1 t ------------------------------- -----•--------•------------------------ ---------------------- --- ' ! hereby certify that I have prepared this application and that the work will-6e done in accordance with San Joaquin County ordinances, State laws, and rules and regulations. of the San Joaquin Local Health District. � i (Owner and/or Contractor) (Signed) qshowing�nsizof,lot �/ sY --------------------------------- (Title) (Plot plan, location of system in relation to wells, buildings, etc., can be placed on reverse side). ' 1 ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -------------- ---- DATE-------- • •----_------------------:� REVIEWED BY BATE " 1 --------------------------------------------------------- r PER ISSUED:_:=`. -------- -------------- BUILDING �- DATE Alterationsand/or-recommendations:-- --------------------------------------------`---------------•------------------•-------------...---•-----•----------------------•-----•-•------------------ -----------------------------•------=-------•--------------•---- ---------------------- r ---------------------------•----- .. --------------------------- --------------------- ------ - A ..-Date__.----------- FINAL INSPECTION BY: - I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street �� 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California `� Manteca, California Tracy, California ES-9-2M Revised W-2100