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APPLICATION FOR SANITATION PERMIT Permit / (Complete in Duplicate) 3 • O G )a. Date Issued __/7/a�- Application is hereby made to the San Joaquin Local Heaifh District for a permit to construct and install the work her This application is made in compliance with C 7 ty &, inanco No. 549. ein described. ff JOB ADDRESS D LOCATI N---- Owner's Name. J.... ----------------------- -•-------------- - --- -------------------------------------------------- - --- ---- - Phone._-- ------ Address ----� ----=-- ------ - --------------------------------•------------------------=---------------------------------------------------------------------------- -----------•------- Contractor's Name_ - ------- Phone + Installation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ ❑ Mjotel ❑ Other ❑ Number of living units: Z--- Number of bedrooms Number of baths Z. Lot size x 1%W- Wafer Supply: Public system Community system [] Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam El Clay E] Adobe �ardpan ❑ Previous Application Made: Yes ❑ No Q New Construction: Yes QPNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)) Septic Tank: Distance from nearest well. 10._..Distance from found ion.-----1 /.._____..Mat ri l__.__...._.__ /�_ No. of compartments---------- - ----- ---Sizel_ _.x. xLiquid depthl----� '------- ---Capacity..]vot_A,71_ Dispo Fiefd: Distance from nearest we l Distance from foun tion_... _Distance to nearest lot ]in e Number of lines -_ Length of each lin�iP . ---------- g - �, Width of french------ --- Type of filter materia _ �- .'� r ! epth of filfer material..._-_.�_8� r Total length Pit: Distance to nearest well ...__.__.__Distance from foundation.................._Distance to nearest lot line._--....._.__... ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth----------- --- esspoo : Distance from nearest well________________Distance from foundation_.-----------------.Lining material- -_..__-..______....____. El Size: Diameter------------------------- ------------Depfh----- ---------Liquid Capacity----------------------------gals. Privy: Distance from nearest well______------------------------------------------Distance from nearest building ❑ Distance to nearest lot line Remodeling and/or repairing fdescribe)_____________________ 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 and regulations of the San Joaquin Local Health District. (Signedk______ ____ —-------------------- -----------(Owner and/or Contractor) By:-------------------------------------•-------.---- --- - Title - ---------------------------------- ----- (Plot plan, showing size of lot, location of sys+ern in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___ _______ ___________ . DAT __� - -- -- - -------------------------------------------------------------- REVIEWED BY --------------------------. DATE_ ------------------------------------------------ UILDING PERMIT ISSUED- ------ DATE----------- ------------------------------------------------------------------------------ -------------------------------------- A+erations and/or recommendations______________________________________ � -------------------------------------------------------------------------------------------------------- ------------------------------------------------------- FINAL INSPECTION BY:------- �.Y-__ ---------------- Date.---- ---1..---- -- 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 5-51 Revised W-2100