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APPLICATION FOR SANITATION PERMIT Permit No. " (Complete in Duplicate) Date issued ---- Application is her y made to the San Joaquin Local Health District for a permit to construct a This application is made in compliance with County /Ordinanc No. 549. and install the work herein described. JOB ADDRESS l� D LOCATION-_. _ --- -------------------- ff y ---------------------------------------•----- _ Owner's Name-- - } V 1� ------------------- Phone--F ---- ........•--- ----- Contractor's Name - - _ -------------------------------------------------- ------•-- - - --- --------- --------- ----------•-------- --------------------------------- Phone------------•----------•----------- Installation will serve: esidh e•VApartment House ❑ Commercial . ❑ Trailer Court ❑ Motu 13 Other ❑, Number of living units: _ -_ Number of bedrooms Number of baths .Z-- Lot size -_-_ _ l Q----- '7-•-------------- Water Supply: Public system (/Community system '❑ Private ❑ Depth to Water Table _:-_-_- f#. Character of soil to a depth of 3 feet: Sand ❑ Gravei ❑ Sandy Loam © Clay Loam eclay E] Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feet) Septic nk: Distance from nearest well ✓ ' - l-,J�Distance,from foun�tion_ Materi i No. of compartments---- - 3 0 - `� .4----IQ" Size � x�-------Liquid de14th---------- 1------------Capacity--- Disposal' !� Field: Distance from nearest well �'� � t Distance from foundation-.:,_-_-__'•--_-----_�Distan a .. 1 - o nearest lot lin j Number of lines-----------f3 --- - Length of each line- !' _b_-•4?JV. `(hof trench--_-- �1_____ Type of filter materiel- _ Xrl Depth of filter materi ------- ---------------------- Length length------�--�-�-•----- Seepage Pit: Distance to nearest wall________________ --_-__Distance from foundation--------_-----------Distance to nearest lat'line_---__---_-:----_ ❑ Number of pits----------------------Lining material---------------------------------Size: Diameter------------- --------Depth--------------------------------- Cesspool: Distance from nearest well----------------Distance from foundation--------------------Lining material------------------------- - ❑ ----------------------- --------------------------------------Size: biameter------------- Dep#h . ---- =----Liquid.Capacity= _ -- '� - - _ _ =Y�=- '`" s. r Privy Distance from nearest well______ --_ ------------ ___-----Distance from nearest buildin Distance to nearest lot line_ 4 ...................... - --------------------------------- Remodeling and/or repairing (describe):__-----____----•__--________________ _ " ---- ----------•---------•--------•---•---•---••----_..---•----•--•------------------------------------ `l -� •----------------------------------------------------•-----------------------------------•---------•------------------•------------------ --------•----------------•----•----------------------------- 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 r gulations.of the San Joaquin Local Health District. Si ned .-- -------------------- - ------------------------------------------------------------------------(Owner and/or Contractor) 8Y� - -------- ---------------------------------------------------------- ---------------------------------------------------- (Plot - _(Title)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 Bl�__,_ -- DATES----.----- REVIEWED BY--- --------- -------- ------- ------------ ------- ---------------- --- DATE-1— _. BUILDING PERMIT ISSUED-- �� -------------------------------------------- ----------------------------- --- --------------------------------- DATE----- '- `$ cera#ions and/.or recommendations:. _-_------__-- -- --- ---------- ----- - ------------------------------- ------ FINAL INSPECTION ---- Date------ ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT ; 130 South American Street 300 West Oak Street 132 Sycamore Scree! 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 i