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�PPLICATIN FOR SANITATION PERMIT Permit No1::2_ �f' (Complete in Duplicate) �{ Date Issued .__-- - a-�/.S Y 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. ND' OCATIONJOB DbRESS: T � ----------- -4-1/7# , Owner's Name.-"---- -`14-1-4------- _ ------------------- ----- - ----------------------------------------- Phone------------------------------------ Address_.---------------------- ------------------- ------------------------------------------ -------------------------------------------------------------------------------------- Contractor's Name-•------ ------------------------------------------------------------------------------------------------------------ Phone------------------------------= Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ /--- Number of bedrooms ai4t--- Number of baths /----- Lot size ------------------------------------------------------------ Water Supply: Public system ❑ Community system ❑ Private 0 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 DC New Construction: Yes x No ❑ Y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) P Septic Tank: Qisian�e from nearest welll - ------Distance from fou dation-- -f---------.Mate - (� No. of com artments-----�-_-__________-_Size-- _1C�/- ___--Liquid depth _- ----Ca aci yel Disposal Field: Distance from nearest well_1r®'------Distance from foundation-4�-------------Distance'to nearest lot lines_ Number of lines---------I--_-___�___L__--- Length of each line----fd--------------Width of trench-___a_-4r------------__-_---_ Type of filter material--e- --------Depth of filter material-JI-------------- ------_--Total length----/_- -a--------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_-.-_------:----_ ❑ Number of pits-------------------- Lining material----------------------_Size: Diameter------------------------Depth---------------------------_ � Cesspool: Distance from nearest well-----------------Distance from foundation-------!----------- Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth-- L---=-------------------------------------- --_---Liquid Capacity---------------------------gals. Privy: '! Distance"from nearest,-well--t-- =-_ -_ Distance from nearest building---------------------------- - ❑ Distance to nearest lot line------__-------------- � -------------------------- -- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------•----------------------- -----------------------------------•-----------------------------•------------------------------------------------- -------------------------------------------------------------------------------------- --_- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- ---- -- 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, anrules and regulations of the San Joaquin Local Health District. 1[� -------------------------------------------------------------------Owner and/or Contrac(Si (Signed) r By:----------------------------------------------------------------------------------------------------------- =------------------(Title)---------------------------------------------------------------- (Plot plan, showing 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-- -"-:7--f- {}` - -- -- -- ----- ---- BUILDING PERMIT ISSUED - -------- -- --'�--------------- ------------------- DATE Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY---------/�-------------------------- - ---------- - Date----------- l �. 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 8-51 Revised W-2100