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�✓ 3� APPLICATION FOR SANITATION PERMIT Permit, No. .. +_.. (Complete in Duplicate) � Date Issued _ � 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 compliant with County Ordinance No: 549: JOB ADDRESS A LO ATIO ... ------ =� •'--I.. =- - Owner's Name - ------ ------- -- Phone . Address-----------------r ' -- ------ -------- ---- --------------------------------------------------------7------------------------------------------------%--------- Contractor's ---------- ----- Contractor's Name- ----- -- --------=- --- ------ --------- ---------------------------------------------------------- --- Phone Installation will serve: Residence part en House ❑ Commercial ❑ Trailer Court's " el ❑ Other ❑ Number of living units: _. .'.__ umber of bedrooms --4- Number of baths .../.. Lot size -.-: Water Supply: Public system Community system ❑ Private ❑ 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 R No ❑ New Construction Yes e No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well__ Distance [ froun tion...1_Q........M00"- - ___-- I No. of compartments.__._ t PacitY --- ____.-_Sizex -Li Liquid dep1h_____ _____ Dispos Feld Distance from nearest well Distance from foundatio.�n; 1 -Distance to nearest lot lin Number of lines.. +��_____;Length of each line&�`--1_X_ 7.Width of trench ________�t_ , Type of filter materi If+Aepth of filter material.------/_$__1_-___Total length----,----- _.-- --------- Seepage 1-Seepage Pit: Distance to nearest well------ ---------------Distance from foundation---------------------Distanc-e.to nearest- 0 earest❑< Number of pits--- -------- ---- Lining material-----------------------Size: Diameter..............•--------.Depth_..... _•-----. ..._.. Cesspool: Distance from nearest well_________________Distance from foundation_----.--------------Lining material----_........................ ❑ Size: Diameter---------------- Depth ----- ---___-____-_•___Liquid Capacity 77 Privy: Distance from nearest well.................................. _-_____-____Distance from nearest building ❑ Distance to nearest lot line------- ------- --- ---------_-------------------- ------- -------- _ ...., Rern4g and/ repairing (describe):-- --------------- -� `� ---- , \ - --•- •-•- ------ -- - _. .... i+ ----- ------- ----................. -•------ -------- --_---- -•--_--•-_-... ------ -- --- ------- ----_•. _--_---- ------ 1 hereby certify that,.) have prepared'this application and that the work will be done in accordance with San Joaquin Cal ordinances, Sta5fo laws, and rules and regulations of the San Joaquin Local Health District. (S•9nei d .)--- -•---- ---------------•---. --•---- ----- ------- --------- --------- ----.--- •-------- ----`---- . __.----- --------- ---------_(Owner and/or Conte) 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 V BUILDING PERMIT ISSUED--- --=-- ----------- ------- DATE.... Alteration and or re mmendatian ._ Y ------ --------- _--- FINAL.INSPECTION BY:--------------- - - ------------------ 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