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APPLICATION FOR SANITATION PERMIT Permit No. {Camplefe in Duplicate) ' (J Date .Issued _�-� i ,��j Application is hereby made to the San Joaquin Local Health District for a permit r This application is made in compliance with County Ordinance No. 549. to construct and install the work herein described, JOB ADDRESS AND LOCATIO ------------ -- Owner's Name --------------- ------ Address_._ ----------- ------ Phone.- on rat ors Name_ Ail --------•----•-- P ---- e Installation will serve: Residencq artment House E Commercial _ Number of living units: _ ❑ Trailer ❑ Motel ❑ Other Numb r. of;bedrooms _ ____ Number of laths -001 Lot size _-_____ © _ Wafer Supply: Public system mmunit system �----------- f -In Wafer Character of sail to a de-pth of 3 feet: Sand ❑ Y Gravel ❑PrrSandy❑LoaDmeOh to Loam _Cla ft - Previous Application Made: Yes No ❑ Y ❑ Adobe ---H �d ❑ -Pd'ew Construction: Yes �Na ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pe miffed if public sewer is available within 200 feef.)�Se ticTank: dotance tomo artnlaresi wail-__ ._-�Oistance from foun ation__ 1p ants--- �.'' ' Size- t--�J -'---.Matori - -- i �,�`' Liquid depth---- Capacity Disposal Field: Distance from nearest well_ pis ante from fo dation__ _____ 1____.._.Dist Number.of lines_ _-----.: �, ante o nearest lot line_________________ ' Length of each line___ ______ �Midth of trench--____ �- �t a f Type of filter materia moi-•-__-?,.-:Depth of filter material--_ Seepage Pit: Distance to nearest well-------------- Total length-------- _- - 0 �+------ '--•--------- Distance from foundation.................. Distance to nearest lot line-_._-.._-_--___-_ ❑ Number of pits._------------------Lining material-----------------------Size: Diameter----------- -- Cess oal: --------Depth-------------------------- p Distance from nearest well----------------- from foundation----------1------- ❑ Size: Diameter._- Depth Lining material Liquid Capacity--------------- --------gals. Privy: Distance from nearest wellA ,_::,_, �pistance=from nearest buildin ❑ Distance to nearest lot lineI g ----- ---------- ----------------------- ----- Remodeling and/or repairing (describe:----------------------------------- - - --------------------------------------------- ------ ------- ------------------------------------------------ -------------------------•-- _ - - ----- ---------------------------------- -----------------------•-------------- = "�---•---------------•---------------------------------------------------------------- I hereby cerfifylfhaf I have prepared this application and that the wok will be done in accordance with San Joaquin County ordinances, Stattee llawws, and rules and regulations of the San Joaquin LocWHealfh District. (Signed)-- r. -----------(Owner and/or Contractor) ----------------•----•----------------------------•---- ---- (Title) (Plot plan, showmg,sae of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). ' FOR DEPARTMENT USE ON_ LY APPLICATION ACCEPTED BY ------------ ------------------------ -- REVIEW`-ED' BY ="'------------- ------------ DATE _ ----- ------ I BUILDING PERMIT ISSUED-------•------•---------- - ------- ------- ------- -------- ------- ------------ DA7E ------ -------� - ----------------- ------ DATE -------------- ------------ Alterations and/or recommendations__________ _ ------------------ ---------- ---- - ----.-----rte._ ------ ---- _ : VN - -------------------- ---------------------------- FINAL INSPECTION BY:-----------/ lc.' n ------------- �� `.•� ate ---- ----- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak StreetX Stockton, California 132 Sycamore Street 814 North "C" Sfreef Lodi, California Manteca, Californiar Tracy, California ES-9-2M 10-52 Revised W-2100"