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APPLICATION FOR SANITATION PERMIT �. . Permit Nod�+►---kV----• - (Complete in Duplicate) Date Issued -. !U---- to construct and install the work herein described. Application is hereby made to the San Joaquin Local Health District for a permit This application is made in compliance with County Ordinance No. 549. e JOB ADDRESS AND LOCATION-------------1-3 --------- tPhone------- ----------- Owner's - Owner s ame.----------------------------------------- ---------- _ -------- ..__ --- Address-------------------------------------------------------------------- Pone---------------------------------- Contractor's Name---------------------------------------------------------- - ------------- - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ...t--- Number of bedrooms ----I--- Number of baths ---I---- Lot size ______________________ ------------- ------------------------- Water Supply: Public system VO communitysystem '❑ Private ❑ Depth to Water Table -------- ft. PP Y� Y Hardpan Gravel Sand Loam ❑ Clay Loam ❑ Clay ❑ Adobe® ❑ Character of sail to a depth of 3 feet: Sand ❑ ❑ Y Previous Application Made: Yes ❑ No ] New Construction: Yes op No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest well_______________ Distance from foundation----.________-_.___.Material_____-_______-_________------------------- --------------Size--------------------------------Liquid depth--------------------------Capacity--------- ❑ No. of compartments-____-_ __ Disposal Field: Distance from nearest weld__________ ______Di from foundation_--______--___-___.Distance to nearest lot line________.________ , Len th of each line-------- ---------------------Width of trench-------------------- ❑ Number of lines________________________ ---- g Type of filter material------------------------Depth of filter material----------------------Total length-----------------------------------•----- y Seepage Pi}: Distance to nearest well-----__-Linin Distance is aanc e from foundStzieonpjameter- Distance to nearest lot {ine----------------- Seepage ___--_-^--_--- s ❑ Number of pits_-____ g ► ,�_ j hd--._Distance from foundation-__._--VO-------Lining material_____---1`�---------- 1 Cesspool Distance from nearest well------- CPA----------gals. Size: Diameter_ ---�--�.__X -----Deph---------------- ----- --------------------------Liquid a acitY-------- i Privy: Distance frorn nearest well------------------------------- -------------------------------------------------Distance from nearest building___________________________________-___. ❑ Distance to nearest lot ine_______________________________________ ---------------------------- --------------------------- ------ ------------------- ---------------- -------------------------------------------------------------------•-----------------------•-----------••---... Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------- - ---------------------------___ -------------------------------------------------I--------- ------------------------------------------------------------» - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules nd regulations of the San Joaquin Local Health District. (Owner and/or Contractor} Title---------------------------------------------------------------- By:___`_____--`____--- buildings, etc., can be placed on reverse si e]. (Plot plan. showing size of lot, location of system in relation to wells, FOR DEPARTMENT USE ONLY ! DATE--------------a -�16-/ Z----------------------- u APPLICATION ACCEPTED BY-------------------------------------- u � ------------------------------------------- - DATE------------------ ------ --------------------------------- REVIEWED ------ --------- --------- REVIEWED BY--------------------------------------------------- ---- ----------------- DATE-------- ------- -------- -------- ------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------- ------- ------- ------- ------ Alterations and/or recommendations;----------- ----------------- --------------------- I -- ----------------------- ---- ----------------- --------------------- --------------- ---------- ------ -- --------------------------------------------------------------- ! ------------------------ --------------------------------------- --------------- ------ - Date----- -�--- ----- -- ----------�--------- ----------------------- FINAL INSPECTION BY---------- ---- --- -------- -- --- -- ---� -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street til4 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y. ES-9-2M s-51 Revised W-2100