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APPLICATION FOR SANITATION PERMIT Permit No S ' (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 compliance with County Ordinance No. 549, yy�� JOB ADDRESS AND LOCATI -------------- . --•------>)-'----- 4�------- Owner's Name----------- _i - -- -- ---------------------- Phone_q----�-/--�- ------ Address-------------------------------------•---- Contractor's Name------------------------- •-- ------------- - • ---=------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residencepartmenf House ❑ . Commercial ❑ Trainer Court ❑ Motel ❑ Other ❑ Number of living units: __1---- Number of bedrooms I---- Number of baths .__!____ Lot size --------4-3 ") Water Supply: Public system ❑ Community system fl Private epth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe�5rcipan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 9__tqo❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tSeptic T Distance from nearest well-----------------Distance from foundation__________,__.Material------------------------------------------------- No. of compartments-------------------i------Size--------------------------------Liquid depth--------------------------Capacity---------------- Disposal Fiefd. Distance from neares weli� ---------Distance from fou ndaf' 1-0-4---------Distance to nearest lot lin j_S__ Number of lines__________ ___ �__� Length of each line_____ ___ ____ __ Width of trench_______ I Type of filter mat erial__,5._�_)__ _�.-Depth of filter material____- f� --_---Total length_______�--0 -.- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-__-_____________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- . Cesspool: Distance from nearest weEl-----------------Distance from foundatior-------------------.Lining material--__________________________________- ' ❑ Size: Diameter--------------------------------------De th---------------------- -----------__ -Li Liquid Capacity p - -------------- q ----------------- - -----gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-_-----____________-_-________________-. ❑ Distance to nearest lot line-- ------------------ -- - -------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)------------- t------ ------•--- ---------------- ----------------------------------------------------- �--------- -------------?7216-ouf------------ ------------- ---------------- d - --- - --- - - 41 -- -- - ---------------- ----- ----------- I hereby certify th I have prepared this pplication and at the work will be done in accordance with San Joaquin County ordinances, State aws, and rules regul ' ns of a San Joaquin Local Health District. [Signed-- -- ------ ---------- - ---------------------------------------------------------(Owner and/or Contractor) B (Title)_ - -- - - --------------------------------------------------------------- (Plot plan, showing size of to , ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - --------=`------------------------------------- -- DATE------- r' REVIEWED BY - DATE ------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or ecommendations------------------------------------------------------------------- --------------------------------------------- - - --------------------- = ¢ 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