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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date lssued�'�_'_'s' Application is hereby made to the San Joaquin Local Health District for a permit to constFuct and install the work herein described. This application is made in compliance with County Ordinance No. 549 �r �y JOB ADDRESS AND LOCATION.--� _-------- ----' _ �_ — ------------------------ ---- P Owner's Name___ !�Olr ----- -- �� --- ----••---------------------- -•------------------ hone------------------------------------ ----------- --- Address ------- - --•- A ��' '------------------------------------------------•---------------------------------•--------- ------------------------------------- ° "" Contractor's Name__. �""="�°'--------------- - - ------------------------------ Phone-- a' ------ ----- Installation will serve: Residence ( " Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 Number of living units: --- `Number of bedrooms ___,,Number of baths I__- Lot size ___�'�_ �_��_�___________________ Water Supply: Public system bK Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe IN Hardpan ❑ Previous Application Made: Yes ❑ No itme New Construction: Yes ❑ No M,, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Distance from nearest well_________________Distance from foundation---------------------Material------------------------------------------------ - _4 � No. of compartments------ -------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest welly ---•_.Distance from foundation_____ ____Distance to nearest lot line__.. a_- __ umber of lines-------------Z _ _ Length of each line-------- Q- -------Width of trench_-___ _4!_"__________ Type of filter material._ --------------------Depth of fi{ter -------Total .length_____- ____ # Seepage Pit: Distance to nearest well_____________________Distance from foundation......... .----...Distance to nearest lot line________---_-_-- ' ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h-----------_--------------------- Cesspool: Distance from nearest well__________-____-Distance from foundation__----------------- Lining material_____--_____--_______________________ 0 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------_------------------------------------Distance from nearest building--------------------------.___-__________- ❑ Distance to nearest lot line Remodeling and/or repairing (describe) �f ------- ---- ----- r --------••---•--------•----•---------------•--------------- -------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------=-----------•----------------------- 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 and regulations of the San Joaquin Local Health District. (Signed __}�..__r_--------------- _ _ ---------- --------(OW-mea-errd/or Contractor) SY� I ------------------------------------------------------------------------(Title)- f ----------------------------- (Plot plan, 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---------------- ------ DATE --- --------------------------------------- ------------- -------------------------------------- ! - -------------- ------------ --------- ---- REVIEWED BY--------------------------------- _ DATE- 4-3,7 ATE ., -- BUILDING PERMIT ISSUED - -- -- _ ---------------------------- DATE € Alterations and/or recommendations-.------------ --------------------------------------------------------------------------------------------------------------r f -- ------------------------------------- ----------------------------------------- 7 FINAL INSPECTION BY: - -'--------------- , ------ Date- - --- -----��. SAN JOAQUIN LOCAL HEALTH DISTRICT 13D South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100