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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued Application is eby 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 Coundinance No. 549. , ------------------------------- JOB ADDRESS A ATI _J 1,Z �� ----- e - Owner' Address--------- --------- ------�` A------ ---------------------------------------------------•-------------- -----••--------------- Contractor's Name----- -------- -------- ------ Phone-------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote) ❑ Other ❑ 1 i Number of living units: __-1l-- Number of bedrooms ---,?4- Number of baths ___I__ Lot size __ _ ---- r- -�•------------------------ Water Supply: Public system [1Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe[Hardpan 0S tion Made: Yes No E / New Construction: Yes �o ❑ Previous Application ❑ L� TYPE OF INSTALLATION AND SPECIFICATIONS: iz� (No septic tank or cesspool permitted if public sewer is available within 200 feet. r x -�-- - Septic Tank: Distance from nearest well__ _ _______Dista n f o un ion--- --------Mat4e �ia l__ / [� No. of compartments-----___-_ ------Size-- Liquid de th--------- ------ ---Capacity------� -- 7 Dispos ' Field: Distance from nearest well.---- --------Distance from found tion___�"ks�_____ .Distance to nearest lot line_ s>_ _. Number of lines_____________ _ _ Length of each line-&K-1,0--, ��.Width of trench___ __11�i___ __--�______.__ t, -------Total len th f N Type of filter material epth of filter matenal________� g 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 well-----------------Distance from foundation--------------------Lining material__________--____________________-____. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gal S. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------__-_-------- ❑ Distance to nearest lot line----------------- ----------------------------------------------------------------- Remodeling and/or repairing (describe)----------------------------------- ----------------------------------------------------------•----------------------------------------- --------------------------------------------------•-------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- ----- ------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------- 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 .eguI ions of the San Joaquin Local Health District. � (Signe )- _ ___.___ __________________(Owner and/or Contractor) --�---- ----------------- ---- - ------------- Title (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 8Y DATE__.�i _________________________________________________ ----------------------------------------------------------------------------------------- REVIEWED BY-------------------------------- - DATE Q - BUILDING PERMIT ISSUED-------------------------------------------------- --------------------------------------------------- DATE------ ----------------------------- r' ! i . Alterations and/or recommendations:-----------�� ,J ----'--------?'-•------=---------- _- "�'�'? -= . -' --- ----- --------- --- - -------------------------------------------------------------------------------------------- s ---� - - ------ -------------------------------------------- ---- - ----------------- ---------------------------------------------------------- ----------------------------- -------------------------------------} . _ ---- ------- FINAL INSPECTION BY: Date_ ,.. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street J S 814 North "C" Street{ Stockton, California Lodi, California Manteca, CaliforniaJ Tracy, California �L ES-9-2M 8-51 Revised W-2100 )