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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 or herein escn ed. This application is made in compliance with County Ordinance No. 549. ,�} _ ------------ ----- - JOB ADDRESS AN ALOCATlO _ - -------r- �---- - -�------- --------- Owner's Name ' _ � ? If '� `� -Z 4----------------------- Phone_ Address _ s ----------------------------------- ----------------- --- --:"i - --` T""-'------- ---------- 4�-"-+-L-` - --------- Contractor's Name---------- ---- ---- ----------------- one Installation will serve: Residence Apartment ouse ❑ ommercial ❑ Trailer Court ❑ Mo I ❑ Other ❑ Number of living units: --�_-- Number of bedrooms __ ___ Number of baths __ Lot size __�__/�o--I-------- ---Z------ = Water Supply: Public system ❑ Community system ❑ Private 010`9 Depth to Water Table'To- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ NoO New Construction: Yes f No ❑ J TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) c Distance from found tion___ __ -Material_ _ �° ------- Septic Tank: Distance from nearest well_!Q!0_�"' �`` No_ of compartments------------ Liquid dept ---------'C. - Capacity Size____.___ Disposal Field: Distance from nearest well___;�_1--__Distance from foundation____J___-,____.Distance to nearest lot ] Number of lines-----------I_________�____.____y�-Length of each line-------5d_�'j>--r= _.Width of trench--- _ ________________ C, Type of filter material__s� _ -Depth of filter material--------ItF---.---Total length--------4_0-----------s-,-�-_.- Seepage Pit: Distance to nearest we{l__�_ J-.-----_Distance fr fo nclafion-______ _zJ---.Dist nce to nearest lot li�e____i✓-__ _ Number of pits__________I_______--Lining material__— _Size: Diameter____, _________-.Depth_____' - .. ______------ Cesspool: Distance from nearest well-----------------Distance from oundation--------------------Lining material-------------------------.----------- ❑ Size: Diameter--------------------------------------Depth__ -------------°-.-r --------------------------- Liquid Capacity gals. 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-___________________ Distanceto nearest lot line---------------------------------- -------- ;„----------------------------------------------------•---•---------------- Mir Re .odeling and/or rep firing (describe): C_ f. `"�`' �' - ,y �y Lrl1" �n� ----------- -------------------- – ---------------------------------------------------------------------- -----------/that the hereby ify that 1 have prepared this application an /that the work will be done in accordance with San Joaquin Count ordinances, ate laws, and rules and regulations of he San Joaquin Local Health District. Si ned (OwnerOr Contractor]- A ( g ]------ -- - �' ''�- - � M r _______ __ _ .. F Imo. Title ----------------------------------------------- (Plot pian, 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------------- --------------- V --------------- ----------------------- DAT E _ REVIEWED BY--------- = DATE- BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------- DATE-- i = Alterations and/or recommendations------------------------ ---------------------- ------------------------------------------- -----------------------•--------------------------------------- ------------------ ------------------------------------------------------------------------------------------------------------------------------------------------- - ---------------------------------------------------------- ------------------------------------------------------------ ---------------- ----------------------------------------------------------------------------•-- FINAL INSPECTION BY-------- ----------------i --- ---------------- 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 E5---9-2M 8-51 Revised W-2100