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APPLICATION FOR SANITATION PERMIT Permit No. ._ _. _ (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. JOB ADDRESS AND L CATI N------- -------- --- ----- - --- -- -----------------------•-------- Owner's Name------------- ---e------- -•--- •. /- Phone- --------------------------------------------------- Address---------------------- --------�- - --•- ------.- --- -------•-------------------------------------- Address--...----------------- Name------------------- --- ------- - -- ---- Phone fes_— Installation will serve: Residence R�'Apartment House ❑ Commercial 0 Trailer Court ❑` Motel ❑ Other ❑ Number of living units: /___ mber of bedrooms __Number of baths __/_ Lot size ____, _._ _ ____.___________.____ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla;Loam ❑ Clayi❑ Adobe E9`14ardpan ❑ Previous Application Made: Yes ❑ No ff-�New Construction: Yes No [moi HA/VA: Yes D No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Se y - Distance from nearest well_________________Distance from foundation--- ----------------Material------------------------------------------ ------ N o. ____.No. of compartments--------------------------Size-------------------------------Liquid depth--------- i---------Capacity----------------------- ;r po Fi Distance from nearest well_________________Distance from foundation------------------;.Distance to nearest lot line------_.___.__- ' Number of lines-----------------------------------Length of each line----------_-4----------------Width of trench----------------------------------- Type of filter material-------------------------Depth`of filter material-----------------------Total length--:_-.--_--_-----------------------------. Seepage Pit: Distance to nearest well-4--�------------Distance om oundation----________________Distance to nearest ottige------S____._ ^� Number of its___. Linin material p Lam' p �----------- g ---- ------M'-*__.Size: Diameter `«��- -De th---,��-' -°------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-__.___----____.__._______.__-______ ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity------ ------ --------------gals. Privy: Distance from nearest well-_-_--____-----_--------------------------------Distance from nearest building------------------------------------------ ElDistance to nearest lot line ------ --------- ----------------------------------------•- ------------ -------------------------------------------•-------------d Remodeling and/or repairing {describe):-----------------------------------------------_-•------•-----------------••--------•--- _ = ---------------------------------- ------------••-----...-.--------------------------------� -----------------------------------------------------------------------------------------------------------•--------------------,----------------------------- ! hereby ce ify that I have prepared this application and that the work will be done in accordance with San Joaquin County G ordinances, S e ws, and rules and egulations of a San Joaquin Local Health District. d ' x F 6� (Owner and/or Contractor)(5i (Signed) T ) ----- --BY• --------- f ( itle (Plot plan, showing size of lot, location of syste n relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY E APPLICATION ACCEPTED BY- - - -- ! DATE_ - --------------------------•------------------------- _.: =' - DATE. "" REVIEWED BY BUILDING PERMIT ISSUED-- I-0 DATE____ _------------- Alterations and/or recommendation ------------ -------- --------------------------------------------------------- ------------------- --- ------------------------------••------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--- ------------------------------------------------------•--------------,----------------------------•----------•---------------------------••------------•---••---------------••----------------------------.- -•--------- 5 ----------•---------- •------------ ----------------------------------------- -----------------------------------------•---- ------ ---------------------------------------------------------------•---------- --------•--- FINAL INSPECTION BY:.-------- r?+Z - --------------------- Date------ -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strest 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 FP CO.