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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued the work herein described. App ication is horeby made to the San Joaquin Local Health District for a permit to nstruct and install e This application is made in compliance with County Ordinance No. 549. �� - , = ,✓�' ' - ----- ------------------------ JOB ADDRESS AND LOC1°1,TI0 .3 r', -fs� (- --- ------------------ Phone----------------------------------- Owner s Name____________ ____ _ - r Address----------------------�--- -- - -�- - - � - �- ------ --- � / Phone._ L- ---- ----- Contractor's Name__-_ Installation will serve: Residence ] Apartment House Commercial ❑ Trailer Court ❑ Motel�❑ Other ❑ Number of living units: -" _"_ 144ber of bedroorrfs tatumer of /-___ Lot size ___"_ -- .1 ---------- Water Supply: Public system M Community system ❑ Private E] Depth to Water Table ________ ft. ,. Character of soil to a depth of 3 feet: 'Sand ❑ ravbl ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe [21, Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: 'Yes Er No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool perrrlitted if public sewer is available within 200 feet.) Septic Tank;,.-,- Distance from nearest well ---------- --- -_-__ __ Distance from foundation___________ Material _____ ______________________________ ;Capacity No. of compartme4s------------------------ ion -- - Size.. _ - ----Liquid depth /! j �i `-- _:_Distance from foundation-_14±__ __-Distance to nearest lot Llne ��-.-- Disposal Field: Distance from near swell �_" Number of Length of each Line__:__�' __ j `.Width of trench_ Type of filter matefial.1_."►_.�)_%r -__'Depth of filter materiaL_ Total length______(�a__ _ _______________ _____ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-_-_-_________-_ (f� ❑ Lining ------- Number of pits-------�------------- material-----------------------Size: Diameteh-----------------------.Depth-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------______Lining material___-______---"____-___-_____---_____-. ------------------Depth-----------------------------------------------i Liquid Capacity---------------------------gals. ( n ❑ Size: Diameter------------------- --- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____-_-_______-___--____--___--__.-___-_. ' ❑ � 1 ------ ------------------------------------------------- Distance to nearest+lot line____-__ _. -- - -- � -- ' �C ------ 1 Remodeling and/or repairing (describe: ---------- �. -- ---------------- ` ------------------------------------------ -------------------------------------------------------------------------------------- -- ------ ------------------------•------------------- ----------------.------- ,;;------------------- I herebycertifythat I havePrePared this aPPlication a�dtka+the work will be done in accordance with San Joaquin County ordinances, State lawsyand rules and regulations 'the San Joaqui Local Health District. k -C f (Ow ran------ orC Contractor) (Signed - `/' r - - ---------(TitIe). 1 BY:----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FQJt DE Tlvi . T USE LY f `,-•�---- DATE----/""----Z- APPLICATION ACCEPTED BY_."-___ - - ; -...... . �. -1 " DATE----------------------- REVIEWED BY----------------------------------------- ------------------------------------------------------------- --------------- ------------- BUILDINGPERMIT ISSUED-------------------------------------------------------- ------------------------- DATE Alterations and/or recommendations:----' --------------------------------- ---------------------------------------------------------------- .------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ----------- -------------------------------------------------- FINAL INSPECTION BY:---------_ --------- - L ` 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-9-2M 8-51 Revised W-2100