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APPLICATION FOR SANITATION PERMIT Permit No.ffy .-. _ _ (Complete in Duplicate) Date Issued Applica{ion is hereby 'J made to the San Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinan o. 549. JOB ADDRESS AND ATI N- - �-- --•._ ----------- --------------------------------••--------------------------------------- Owner's. Nam - ---=-------- ----- --------- Phone--- --- Addref--•---- _- 1. ------------------------------------------------------- Contractor's ------•--------••- Contractor's Name - 4!--------------------------------=--------------------------------- --------------------- Phone--. . Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court E] Motel El Other E]Number of living units: cam._ Number of bedrooms..1� L- ___ Number of bathso -- Lotisize /Q _______________________________ Water Supply: Public system, Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑r Adobe Hardpan ❑ Previous Application Made: Yes ❑. NoNew Construction: YesA No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic T.nk: Distance from nearest well_____.___'__.__Distance from foundation--------------f.---.Material__________._____-__--._________._________-____. No. of compartments--------------------------Size.__...-i__=---•- ------Liquid depth--------------------------Capacity l Disposal F' d: Distance from nearest well_________________Distance from foundation-._______.___------Distance to nearest lot line-------_.________ :. Number of lines-----------------------------------Length of each line------------------------!-----Width of trench.--------------------------------& YP ,�__4-�"'____bistance filter material-----------------------Total length--------------------,--------------_--__ Seepage Pit: Distance tonearest(well, Depth f m f u'ndation___----/Z:._..Distance to nearest lot li _____�__-_ j I` X Number of pits.._._!---- ----Lining material _ -___ r Size: Dia mete�___,3_1--__.________Dept h-------- Cesspool: Distance from nearest well______.______---Distance from foundation------------.-I----.Lining material-----___________.__________-.__-. ❑ Size: Diameter--------------------------------------Depth------------------- ....Liquid Capacity ------------gals. r t Pi"ivy:&" Disfance-r== - Ir nearest"well___--={,_z�. '--_--_%:"_______________�-Distance�-fro m,neares#-building._;_______.,_____,_-_-__,-„-----_ ❑ _ Distance to nearest lot I;ne------------------- =------------ --•-------- - -------- - r Remod n repairing (describe):____ ,� S �-y T - ----------------- ----- - ----------------------------------�:�-----------------------------ti- ---•-----------------------------------_---------------------------------------------------•------ ----------------------_ - ... �----- � .. w I hereby-certify that I have_prepared this application and that-the work will be done in accordance with San Joaquin County ordinances, State la s, and rules nd regulations of the San Joaquin Local Health.District. Signed �•'--- --------------------------------�-�Avner and/or Contractor] V ------------------------------------------------------------ -------------(Title)-----------•- -1- �--------------------- ----- (Plot plan, showing-.size of lot, location of system in relation to wells, buildings, etc., can be placed on verse side). FOR DEPARTMENT USE ONLY - - APPLICATION ACCEPTED BY------------------- ------- -------------•--•-------------------------- DATE--- I REVIEWEDBY-------------------------------------------------------------------------------------------------------------•--------------- DATE------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-=------------------------- Alterationsand/.or recommendations:---- -------------------------------------------•------_-----------------•--------•-------•-----••----------------------••-------•-------------•-------------- -- - - ---------------------•--•----------•-•-------•--------------------- ------- -------------------------- ------ --------------------------------------- ------- ------------#- - --••---------------------------------------•------------------•---•-------------- ----------------- f FINAL INSPECTION BY: = � � - -------------------------- ------ - - _ SAN JOAQUIN LOCAL HEALTH DISTRICT 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 ; Revised W-2100