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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) G Date Issued Applical-ion 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 with County Ordinance No. 549. JOB ADDRESS AND LOCATION_________ . Owner's Name --------------------------------------------- Address---------------------- ------•-----•-- - - -------------- ----------------- --------------- -- Phone.--------------- ----------- ---------- ---------- Contractor's Name_... .._:._ - 1 L rr Installation will serve: Reside partment House ❑ CommercialTrailer ❑ Court ❑ Motel ❑ Other ❑ Number of living units: _I -�- Number of bedrooms _ --PJuTnber of baths NumblX _ - _ ---• - Lo} size ----- ---- - ��-�-�-j- ----•--- - Water Supply: Public system ppY� uy ommunity system E] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sane! ❑ Gravel ❑ Sandy Loam F] Clay Loam ❑ Clay ❑ Adobe[I_y- rdpan ❑ Previous Application Made: Yes 9 � New Construction: Yes �o[j TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �ptic Distance from nearest wail--- ----_,Distance from foundation-.__-""--" - No. of comparfinenFs__ . ..... Size------------ -Material. .-- _-- .- ------ --- --- --------------------Liquid depth..- -- - - -osa ...Capacity----- --------- j Disposal field: Distance from nearest well oundation___.----------- Distance to nearest lot line-_""_-"-------- - Number of ____________ _Distance from flines -._ Length of each line Width of french__. - ------ ----- ---- Type of filter material___".---- -__- ___•._---Depth of filter material.___"-----.- r r - --- Total length------- --------------------------------- eepage Pit: Distance to nearest well -AC__Distance rom funda#ion____ _ Dj tante to nearest lot line, N I umber of pits.__..____-- -_ Lining material__.__.t`o_: -elation Diame er__ Cesspool: Distance from nearest well------------- Distance from foundation--_____ -----. - -Lining material-- - -------------.........❑ Size: Diameter---- --- -- ---- fle,�th ---- --- -------- --- --- .. --- Liquid Capacity............................gals. Privy: Distance from nearest urell.._------ ----------- ---------- "."-__.___._Distance from nearest buildin ❑ Distance to nearest lot line_. g"--------------------------------- -- -.- ------------------- ----- - Remodeling and/or repairing (describe)---------------- ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of th n Joaquin L cal Healthjistrict. a (Signed} -- -- - � r and/or Contractor - -- -.(Title --- ) (Plot plan, showing size of lot, location of system in rglaftion to wells, buildings, etc., can be placed onr reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -------- REVIEWED ------ = -------•----------------------- ----- DATE--------- �.------------ REVIEWED BY � ��- ---- - DATE--------- -------- BUILDING PERMIT ISSUED-.--.-. - ------- --- --- Alterations and/or recommendations:--------- ---- -- ---------------- ----- ------ DATE.-.--.--------- -- --------------------------------------- -------------------------•---- ------ ----- r - ------------- - ----------------- -----5=----------------------- -------------- ----- ----- _ r - f------ - - `- _ FINAL INSPJ=CTIg9U BY: f t.) .. - -- ----�----- 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—aM --.G AY .Qp T2 S4