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APPLICATION FOR SANITATION PERMIT Permif No. (Complete in Duplicate) Date Issued plica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 4A1This application is made in compliance with County Ordin Vce No. 549. JOB ADDRESS AND ION { -•-----� _1111-lee Owner's Name--------- - ----------- ---j- --- - Phon #----- - Address � �Da-�-- --------------------•--------••----------------••--•----•---------------------------- Contractor's Na e-------------•-- • ------------------------------------------------ -----------------------•-•--•---•----------- Phone_-AP_� Installation will serve: Residence Apartmenf -louse E] Commercial E] Trailer Court ❑ Motel F1Other i ❑ Number of living units: __ Number of 4drooms __ _--_ Number of baths ___ ___ Lot size __ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl eq ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado b H6rldpa;.�.. Y Previous Application Made: Yes ❑ NoP,< New Construction: Yes 1< No ❑ / \\ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic lank: Distance from nearest well__- �,____Distanc from foundation__.,�Q ___.Mat9ria____________-_. _ ' ------- No, No, of compartments---._ ....._. __.__Size_ _ ! _ __LEquid depth__ __.. _ -�--Capacity..____._ _C>. Disposal Field: Distance from nearer well- _. ..-Distance from foundation___ _ _______.Distance to nearest lot line------ Number Number of lines______ _____________.___ _____Length of each line-_----_ _- ___.____.__.Width of trench.--_____ i Type of filter materia��/L : ______Depth of filter material_._.___ .�_._-Total length__________. Uj Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-------_--------- ,0 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----.-----------------.Depth--------------------------- 0- ri Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________________-.____-_ _F1 - Size: Diameter-.------------_-------- ----------------.Depth-----------------------------------------------_-Liquid-Capacity---------------------: gals. wow, Privy: Distance from rearest well------ __________________________________Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line------------------------------------------------ •------------------------------------I------------------------------------------------------ Remodeling and/or repairing (de scribe):__. }-l _ �_.____ -------------------------------------- ----------------------------------------------------------------------------------------------...------------------------------------•------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta s, d les and regulations of the San Joaquin Local Health District. (Signed.)---- - --- � - Owner and/or Contractor �� By----------------------------- ez ffl_.----------- ------- -------------------------------- (Title) -- ------------- (Plot plan, showing size of t, location of system in relation to wells, buildings, etc., can be place on r arse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B .`�___ DATE_ REVIEWED BY----------------------------- DATE__ -------------------------------------------•------- BUILDING PERMIT ISSUED-----------------f------------ -- - ----------------- - - -- -- _ -- BATE - - Alterations and/or recommendations r ---------------------------- _11 ----.--- ------------------------------------------------------------- - ------------ ----• -- -- ------ - ---- - ------ _ - - -- -- ------- _--------------------------------___------________•_.--____ ------------ r ----------------- JJ FINAL INSPECTION BY: -------- __-__. ?ale f f r ------------------------------ ---- SAN JOA UIN LOCAL HEALTH DISTRICT 4 � //� w 130 South American S+reef 300 West Oak Street 132 Sycamore Street 814 North "C" Street--- Stockton, California Lodi, California Manteca, California Tra y,.Eaiifor ES-9_2M Revised W-2100