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APPLICATION FOR SANITATION PERMIT P mit No. __ ----- j (Complete in Duplicate) -Date Is;,aued "-- - -- 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 ANDLOCATION P --- -e—,-_ ! 't ----------------------------------------------------------•----,------------- Owner's Name --firms Phone__ G` ,1 Add ---------•-------------• --•------------ ress -`�- --- ----------- ---- ---- ---------------------------- Contractor's Name------------- - ----- -- � ---�--'----------------- - ----------------- ---------------------------------------------------- --. Installation will serve: Resi ence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _)''____11Number of bedroomsc�. l- -Number of baths --- Lot size - `�� Water Supply: Public systemx Community system '❑ Private ❑ Depth to Water Table��ft. (� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeW Hardpan Previous Application Made: Yes ❑ No� New Construction: Yes E] N� �( TYPE OF. INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200•feet.) Septic Tarnk;: Distance from nearest Distance from foundation---- ---------Material------------------------------------------------- L'' //JY No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-----------•----------- �Disp❑o }Field Distance from nearest well_________________Distance from foundation-------------------- to nearest lot line------------------ Number of lines-----------------------------------Length of each line-----------------------------Width of trench - Type of filter material-------------------------Depth p - � / Distance______Total length nearest lot of filter material_________________ th------------------------------------- __ SeeV39 Pit: Distance to nearest welt <t - _Distance #� fou anon____... Depth { Lly Number of pits____________________Linin material_ Size: Diameter____. Distance from nearest well_________________Distance from foundation._--_-_____________.Lining material-------------------------------------- Cesspool: ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity---------------------------gals. I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-_-_________--__________..._______--_____. ❑ Distance to nearest lot line_________ -- p -------------------•---------•------------------------------------------------ i Remodeling and/or repairing (describe)_______________� ----• - -----�1�------ ---------------•- ------ --------------------------------•-------------------.._..----------•-------•-----------•------- ----------------------- ,-------------------------------------------------------- -----------------•-•-•-•-----•---------------------------•-•-----------•------•----------•----------------------•---------•- -----------------*------------------ ------ - --------------------------------------------------•--------------------•------------------------------------------------------------------------------------------------------•----•-•------------------------- I hereby certify that I have prepared this application an -that the work will be done in accordance with San Joaquin County ordinances, State laws nd rules d req 1etions of t �oaquin Local Health District. p --- -/Of � -------- ------ -•--------------------------------------------------------------(Owner and/or Contractor) I (Signed} l Tale - ------------------ a---/ 1----------------------- ------------------ --- (Title) �'` BY: plan, showing sizt, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ! R APPLICATION ACCEPTED B - --------------- DATE.;�------------------------------------------------ ------------- - REVIEWED BY ----- ---------------------------------------------- DATE - -- ----------------- ------------ - - ------------------- ---------------- BUILDING PERMIT ISSUED --- -- DATE----------� ------------------------------------------- ------- Alterations and/or recommendations:__------- -----------------------------•------------------------------------------- ----------------------------------------- ---------------- --------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------- -------------------------------------- ---------------------------------------------------------------------------------------------- --------------------------------------------------------- - - ---- - - -- -- -- - --------- --- ------------------------------------------------------ ------------ ---------------------------------------- -------------- FINAL INSPECTION BY:------------W.- f 1_.. Date---- = ---- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT r 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 5-51 Revised W-2100