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APPLICATION FOR SANITATION PERMIT Permit No. _��✓" r2______.. (Complete in Duplicate) Date Issued Applica{ion is hereby made to the San Joaquin Local Health District for a permit to c struct and install the work herein described. This application is made in compliance with County�O}rdinance o. 549- , JOB ADDRESS D ' A ION ----------------------' ---------------------------------- Owner's --- ---------------------- - Owner's Name__. _.. -- _ -- -• - -- - -------------------- ,.. Address__ • Can ractor's Name - --------- -- ------ -r------------------------------•-=---------------•---- Phone - Installation will serve: Residence Apartment H use ❑ Commercial' ❑ Trailer Coui-t ❑ Motel--[-] 'Other ❑ Number of living units: __ ---_ Number of bedrooms Number of baths _/__ Lot size Water'Supply: 'Public system Community system Cl Private ❑ Depth to Water Tableoi t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ Ad ob Hardpan ❑ Previous Application Made: Yes ❑ No New Construction:'Ye No El OF INSTALLATION AND SPE IC FICATIONS! i t (No septic tank or cesspool permitted if:public sewer is available within 200 feet.) Septic Tank: Distance from nearest weII Distance from- ou dation_ f Mater al- No. of compartmen-1s__,c?----------------Size rLiquid depth_,-I _�__Capacity_______ Dis gal Field: Distance from nearest wefi �Distance from fou ndati Distance to nearest lot line_ __ __-__i Number,of lines---------,----_------ ___Length of each line,45�_��_.______-.Width of french_-_-.____�-------x:-_._-- r EE Type of filter material Depth of filter ma rial___._ _ �r____To+al length--------�`�. - --__k,5-S _)6 Seepage Pit:" Distan.ce_to nearest_fwell; -__ �_mfou aotion0-_-_. ..Distance- to nearestlot line_____ing materiaSize:-Number of p!fs._-- _Linime+er_� __ Dep o -`-;�,__ -__ Cesspool: Distance from newest well________________"Distance from foundation__-__---------------Lining material___.____..?_ ______-._________--___--. ❑ Size: Diameter--------------------------------------Depth----- --- -- --------- -------------------- --- ----Liquid Capacity-- ----------------------`---gals. I , Privy: Distance from nearest well---_____________�____-___-__.____._______---__Distance from nearest building----------------------------------------- . r ❑ Distance to nearer#Slot line.............. '= - Remodeling and/or repairing [describe): -77----------------------------- --------------------------.-------------------------- - -------------•-•-- •---------------------•----------------- -------------------------------------------------•------------------------------------------------------------------------------------------------------- ---------------------------------------___-___+____.______-_____--i_______-----___-___-_--.-______________--_--__-__________---_._.-___________----____________-__-_____-____________--__v_________--___________-_________._ 4 _____________________________________________________________________________________________________________________________________________________•___.____._________-__--______---_________.______________________.__-___ . I:hereby certify that I have-prepaied this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and re ulafions of the San Joaquin Local Health District. Si ned { .g )---------- ei��r_j - •------ Owner a?iracf,� r) _. By:_ ------- ----------------------------------------------------{Tit -- ------------ - ,(Plot plan, showing fxe of to ,`location of system in relation to wells, buildings, etc., can be ed on reverse sid f w FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- --------------------------------------------------------- DATE------ r 3 � REVIEWEDBY------------------------------------------ DATE------- BUILDING PERMIT ISSUED --------•-----------------------------•--------- ----------------------- DATE---------- --r-----------T Alterations and/or recommendations:-- ------------------------- ------------------ ---------- - -i _ r '+ i = ---------- - ----- ------ ------ -- -- --------------- ---- FINAL INSPECTION�BY:_..-- --_ ate --- : ` Dr ------�--x---------------- ------- 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