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APPLICATION FOR SANITATION PERMIT Permit No. .......... ... �__ (Complete in Duplicate) oDate Issued Application 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 LOC ---------------- � ' I ON ._____._._- -- -- wner s Name- --------•--- --------------------_-- --------- Address--------- -------------------- ------ Phone_.------- ....... 'I rY—�. - Contractor's Name----------•---------- -----------------•--------------------------------------------------- -------------------------------------------- Phone_ Installation will serve: Residence _.._____.________-._----_•____--•_ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.❑ Number of living units: __.�.._. Number of bedrooms _ ' _ Number of baths _J-__- Lot size _._.......__ Water Supply: Public system ---------------------- Y ��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 9?'Hardpan Previous Application Made: Yes R"No ❑ New Construction: Yes ❑ No E2__ ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation No. of compartments_..:_. -----_-- --Material_ ___•_ Size Liquid depth_ Capacity. isposal Fiel__0 Distance from nearest well Capacity....... ..... -- -.. ..Distance from foundation ..__.._---:-Distah to nearest lot line................. ❑ Number of lines___ ____._. . -------------------Length of each line_.. _ __ 1te Type of filter material11N_121.1:1�1 _-_._ ._..____.__Depth of filter material_. Width of`trench. .. .._..__..Total length--------- Seepage _ Pit: Distance,to nearest well.. -•---`• --- .______.___Distance from foundation ❑ Number of plits------K_- -----------Lining material--- -Distance to nearest lot line, ._ - -_ Cesspool: -- Size: Diameter p .Distance from nearest well.................Distance from foundation -.----.Depth. -- -- -- ----------------- Size: Diameter--------------- Lining ms#eriel.-- -- - - -- Depth -----------------------------------------------Liquid Capacity gals. Privy: Distance from nearest well. .: __ '--'-- --------- ----- --------------------------Distance from nearest buildin ❑ Distance to nearest lot line------ -------•-----•--------•-•---•--------- g--------- ------- ------------------- Remodeling and/or repairing (describe):-:.... . .. ---- ------ ---------------------------------------- ----- hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County ordinances, State law rid rules regulations of the San Joaquin Local Health District. (Signed)------------------- By:.................--•---•- ---- ----•.-•-- ..---•------ -• --------- -- -------- ------------- ------ -- (rile) (Owner and/or Contractor) (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_._._ _-_--_---.-___ REVIEWEDBY------ ------------------ . ---- ----------------------------------------- DATE_•---- ��. ---------- BUILDING PERMIT ISSUED DATE ------- 7 " 3 Alterations and/or recommendations:..._ ----- - ------------------------------------ DATE------ ----------------- .__......._. _- --------------- --------- - FINAL INSPECTION BY:......:.. r, Date... �� 3 SAN JOAQ IN LOCAL HEALTH DISTRICT / 130 South American Street 300 West Oak Street Stockton, California 132 Sycamore Street 814 North "C" Street ES-9-2M 10-52 Revised W-2100 Lodi, California Man+eta, California Tracy, California