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APPLICATION FOR SANITATION PERMIT Permit No. ....... O (Complete in Duplicate) Date Issued Applica+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........ ----_-�/ - Q S_____________ ------------------ Owner's Name1? e_ ,. Address-------- �� /'�1 _ / >... Contractor's Name_______ �r ___...._ Phone. 6- Installation will serve: Residence Apartment House Commercial Trailer Court ❑ ❑ Motel ❑ Other Ell �. Number of living units: ._-_ Number of bedrooms :_=-Number of baths1`.._.1-ot size ' _ Water Supply: Public system 51- 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�Hardpan Previous Application Made: Yes ❑ No ? New Construction: Yes UiL_ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan . Distance from nearest well-----------------Distance from foundation....................Material. _____.--_ -__•_-___ ❑ ompartments------------- ------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposalfil : bi ce from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line................ ❑ um f lines---------------- ------ -- --Length of each line----------_-------------------Width of trench_ Type of filter material-------------------------Depth of filter material-----------------------Total length.......................................... c Seepage Pit: Distance to nearest well - Distance from fottriclation-.2.0- Di id4wce,,to nearest lot line___l� .____. [ � Number of pits------C--- - Lining mate ria Diameter_..._ ----- Depth 25 Cesspool: Distance from nearest well-----------------Distance from foundation..--_-_-..-_-__--. Lining materia--------------------------, ___-- p ❑ Size: Diameter--------------------------------------Depth---------------------------- ------Liquid Capacity-------.---- -------------gals. M Privy: Distance from nearest well ___________________________________________Distance from nearest building ❑ Distance to nearest lot line 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, Stat laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-----. ...... -----------------------1�3--------------------------------------------------- ---------------------(Owner and/or Contractor) By:. o� -----------------------------------•--(Title)---••-` -- -------------------------------------------- (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.------ DATE........... REVIEWED BY------------------------------------ ------:--- -------- -------------------------------------- DATE-------------- -- --------------•----•----------- BUILDING PERMIT ISSUED................................... -----• DATE--------------- f�C Alterations and/or recommendations: ) ----------------- ------- ------ �-S- v -- " - 5 C=----- ---- -------------------------------- ---------------------- -----•---------------------- -------- ........ ------•---------------------------------- --------------- ----------------- ----------•-. ------------....-----------------...--------------------------- -•-•-- FINAL INSPECTION BY:----- ------------- � 3. ----•--------------- Date.---------------------------- ........... SAN JOAQU)N LOCAL HEALTH DISTRICT 130South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Ll ES-9-2M Revised W-2100