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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Permit No.. Date Issued ----- Applica}ion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND ATION---------- -' -- a4�- �-------------------•------•-•---------------------•----------...---------------------- Owner's Name------------ ✓------- --------------- Phone ------------------------------------ Address.............. l ............ '-----------------------------------•----------------------------------------------•--------------•----------------•--- Contractor's Name............/-- -------------------------------- Phone - - - Installation will serve: Residence Apartment House ❑ Commercial ❑ TraileY.4Court ❑ Motel ❑ Other ❑ Number of living units:// �v' ''- ------------"-------•- __-___ Number of bedrooms ___9_ Number of baths ._L___ Lot size --- ______________ - Water Supply: Public system (Community system ❑ Private ❑ Depth to W ter Table4_00ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [R- Hardpan ❑ Previous Application Made: Yes ❑ No 0– New Construction: Yes ❑ No ®'— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool ,permitted if public sewer is available within 200 feet.) e ' Tank: Distance from nearest well_________________ Distance from fpundation-------------------- Material______--_____-____--__ _.---_-----•____-_-_--__--. No. of compartments --------------------------Size-------------------------------- Li uid de th--------------------------Ca acitY-----------------.--- Disposal- Field: Distance from nearest well_________________ Distance from foundation ...................... Distance to nearest lot line ---------- ....... ❑ Number of line�----------------------------------- Length of each line -------_---------------- :Width of french ----------------------------------- Type of filter material_________________________ Depth of filter material ------------- _._-___---Total length •-_--•---__-__-____----____��__._._.. Seepage it: Distance to nearest well f --__Distance from f,,un tion -_:_-__.Distance to nearest lot line _`}-_-___--- ___ - ---i--------. Depth-- � 4 ----------- Number of pits____..-/.__.______ Lining material SF _______---____ iie: Diameter__. Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material ------------------------- .-..__-_____ ❑ Size: Diameter,-------------------------------------Depth--------------------------------------------------- Liquid Capacity---------•--- -----•-gals -------------Distance from nearest building ----------------------------------------- Privy: Distance from nearest well__________________ ❑ Distance to nearest lot line= ----------------------••---------4 ------------------------------------ ...... _-----•--••---------------•------------•-•---•------------- Remodeling and/or repairing (describe): -- - ---- -- -- -- - ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, and rules and regulations of the San Joaquin Local H�strict. w_-'�----'----------- �=-------- --(Ow r land/or Contractor (Signed)----- --------_----- ---------- s �"�- ----�,�G-R (�C/------------------------ -------.(Title)- � = -------- By: ------------------------------- -------------------------------- (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- --------------------------- _-------------------_-- ---- DATE ------------- � - - ---------- REVIEWEDBY ------------------------------------- ---------------------------------------------------------------------------------- DATE ---------------- BUILDINGPERMIT ISSUED ---------------------------------------- •---•----•--------------•-•----------•--------•------•---• DATE _--------------------_------ ------------------------------ Alterationsand/or recommendations--------------------------------------------------_-------------------- --------------------•-------•-------------------•=--------------------------------•- -------•-------------•-•------------......-•---------------••----------------- ---------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:-------- ------------------------------ Date----- 7 r� 4 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 Revised W-2100