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1 t APPLICATION FOR SANITATION PERMIT Permit No. _ �.•� _. .......(Complete in Duplicate) rr} Date Issued Applicatidr� is h�reby made to the San Joa uin Loc q a Health District for a permit to construct and install the work herein described. This application is made in compliance with County rdinance No. 549. JOB ADDRESS AND LOCATIO Owner's Name-__"__.- Address_._ ------------ ------------------------------------ ------ Phone-------"�-dl's---------- _ -------------- -- -------- ---- ontractor's Name _"_._"._"___._._ ---- q ------ Phone-_ -- --- Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- --- Number of bedrooms_ -" Number of baths Lotsize ------------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand El ❑ Sandy Loam ElClay Loam E] Clay [IAdobe Hardpan El Previous Application Made: Yes ❑ No V New Construction: Yes No E]TYPE OF INSTALLATION AND SPECIFIC TIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Distance from nearest well ..Q_�_Distance from foundati n_ No. of compartments-..4- 0_ v �1 / Q...-...Materi Size !� /� /f� Liquid depth_- Disposal Field: Distance from nearest well _ _-_Distance from foundation__...". Distant nearest lot line_- Q ❑ Number of lines f ------- line,;,--5 v V Length of each line_----- ".e''_---____-----Width of french...__ _ _.-_.-__" Type of filter material_.- f�, _c! eph of filter material_.„! � Dt �-,- �.Total length------------ ------------------ Igs., Sepage Pit Distance to,creast welly _Distance fou t-iop /� .,,.Distanfe tonearest lot line"_.-. urrrkse�of _. pits Lrnmg materia t,--Size: Diameter - C sspool: Distance from nearest well-._.".___."_.__Distance from foundation__-__.__________.-Lining material________ ❑ Size: Diameter---- ------------------------------Depth-------------------------------------------- - Liquid Capacity ____________________ _ Privy: Distance from nearest well -------- ------------gals. F1 Distance to nearest lot line__ _ _____________"___ ___ Distance from nearest building g----------------------------------------- "--"--"" - - ----------- - -------- -----•--------------------------------------------- Remodeling and/or.repairing (describe):-------------- �J� ;- ---------------------------------------- --------------------------------------- - - -----------------•------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws d rules d 00pegulations o he San Joaquin Local Health District. (Signed)--------------------- - -- -------- ------ ---------------------- -------------------------------- ----- Owne Contractor By: -------- ..-I------ Title r - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be ed on rev a sid --------------- F R EP ENT USE ONLY APPLICATION ACCEPTED BY_._.._..____________ %' ~ ----------------- --- . ---- --- ----- REVIEWED BY e -------------------------------------- DATE---------- ----' � ------------ ------------- DATE - BUILDING PERMIT ISSUED-------------------------------------------- ------------------------- --"---------------------------------- DATE"." --- --------- Alterations and/or recommendations:.__.-.. "------------ ------------ --- - ------------------------------------------------------------------------------------------------ - ---------------------------- -------- _------------ ------- --- ------------------------------------- FINAL INSPECTION BY: ........... .... i ----V---------------------- 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 10-52 Revised W-2100