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APPLICATION FOR SANITATION PERMIT Permit No.,;�_--...IN (Complete.in Duplicate) /! Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins 11 the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO TION__. _.. I!!_ ----- --- - ' ---------------- ---- ------------------------------------------------------- Owner's Name ------ -• --•--- --------- -- - - -- -- -------------- ----------------------------------- Phone---------_----------------------- Address -----•--- -------------------- Address -" `_ Contractor's Name ¢ ` d ---- . - - Phone--- , --- --= Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: __)____ er of bedrooms I---- Number of baths j--- Lot size ----- `�----Z 4$ --- --_,___-_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam lay Loam El Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No 5r New Construction: Yes 0^0 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu liic/sew is available within 200 feet.) Septic Ta Distance from nearest welli Q4(! : istance nation- - -...... .?MateriI No. of compartments_. _._`S `-_� ll'Liquid depth_-- ,'�.,-GapacitY.... ..__Disposal d: Distance from near t well_ -� _____ stance from foundatio _ .�641 � _...._. e to nearest to -li�_._ _. Number of lines_. , -- Length of each line----- �,,,___-_.Width of trench...__ ------ __,_-- T e of filter material r Type �f- _ !_Depth of filter matenal__I� _____._..__Total. length____.-.- . .................... Seepage Pit: Distance to nearest well_ __________________Distance from foundation---_--------------Distance to nearest lot line----------------- 0 -_-_--_----_---❑ Number of pits---------------------Lining material-----------------------Size: Diameter---------------:-----_.Depth---._----- ------------__------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material Size: Diameter- -----------------Depth---- ...--------------------------Liquid Capacity -------- -----------gals. Privy: Distance from nearest well________ _________------------------------------Distance from nearest building _ .-----------------_,.__-................ ❑ Distance to nearest lot line-------- ------------- -- - Remodeling and/or repairing (describe):__ _-.__ w• ✓�___. ._ _- _ ..!____ ------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------- --------- --------------- -------------------------------------- --------------------------------------------------------------------- ------------------------------- --- ------------------------------------- ----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lows,'And ruless a d re�guul�ions of the San Joaquin Local alth District. - a -7 - ��,` - ---a ------ (Signed) er end/ ,tractor) By:----------- ---- -- -- ----------------------------- --------------(Title)---- -- --------- ----------- ---- ------ (Plot plan, showing size of lob location of system in relation to wells, buildings, etc., can be laced on reverse side 9 P ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____ _______________ __-____ - DATE REVIEWED BY------------ ---------------- --------------- �."'�_""""'------------------------------------------ DATE ----------�i----------------------------------------- BUILDING PERMIT ISSUED......................---------------------------------------------------------------------------- DATE------------------------•------------ - Alterations and/or recommendations:----------- ---------------------------------------- - --- -------------------------------------------- ------------------------- ------ ---- ---- - ------ ---- --------------------------------- --------- -- --------- ------ FINAL INSPECTION BY:-------------- -'r:7------- ----------------------------_ Date------- --- r - 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