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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Applica+ion 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 Ord• ce No. 544. A JOB ADDRESS AND VOTION__,/ ---_ F ----------------------------------------------------------- -------------->--- Owner's Name ______ ____ ____ 9 � - --- - -------- ------ Phone �c�_ Address-_ __ Contractor's Name -------------------------------- --------•--•--------------------••-------- -------------------� -- ---- _--- -- - - - t ---------------- Phone.,? Installatio' n will serve: Residence Apartment Nouse [-]Commercial ❑ Trailer Court / L] Motel ❑ Other E]Number of living units: _/INumber of bedrooms_-_ Number of baths __/-- Lot size ----- - - - -- ---------------------- Water Supply: Public system"'' Community system E]Private ❑ Depth to Water Tabl5r4&ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado�e,�� Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No E]TYPE OF INSTALLATION AND SPECIFICATIONS: �� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic Tank: Distance from nearest well----------------- Distance from �. foundation.--_. No. of Compartments'_ -------------Material--------------------------------•--------------- ' " Size --------------------------- Liquid depth-------------------------- Capacity---------- Dispos I R II Distance+frorr7 nearest weli_�1 -_-Distance from foundation_ -- f . � �Q�. --_._..Distance to nearest lot lir�e.____---,-_ Number of lines .----------------- - Length of each line_-___ _ of filter material ------ ?-------Width of trench.----- ------------------------ Type ____Depth of filter material....... ----:_-..Total length ----------- 11 -------------------- Pe,ea,e- it: Distance 'to nearest well_ --_:----_---___---_Distance from foundation___________________.Distance to nearest lot fine_----_------_-_--1Number of pits ----------------------Lining material -----------------------Size: Diameter----------- Depth--------------------------ool: Distance from nearest well ----------------- Distance from foundation -------------- • -Lining material ----------------- ❑', vSize.:.Diameter_. -_ Depth.. _...----------- - Liquid Capacity--: 9als... . Priv t • _ _. -� �-- ;,,� Y: Distance rom nearest well ---------- ----------------------------- --_---Distance from nearest building- - --- ------- ---- -- --- ------------------- Distance to nearest lot Line___________________ ---------4n, Remodeling a /or repairing (describe}:_- ----- -- ------ --- ------------------ ------------- ._^= V ------------------ --------------------------------------------------------------- ---------------------------- ----------------- __ I hereby certify that I ve prepared this ap 'hcation and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and atlas nd regulatiorof +he San Joaquin Local Health District. (Signed)-----_ _ . . ----- ---------------------------------------------------------- ------ --- - wner and/or Cbntractorj By:--------•------------- = - Title r (Plot plan, showing size of, loca+io o system in relation to wells, buildings, etc., can ) 9 p E' on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE ----- REVIEWED BY -------------------------------------------------------------------------------- DATE BUILDING PERMIT iSSIJED------------- --------------------------------------------------------------------•----------••--- DATE------ ---------------------------------- Alterations ------------------ and/or recommendations__� ,'1- ---! _ ' _ / , - -------------- -------------- (!� ------------------------------------------------- ---------4rZr `"k -:._alp'*. /�_-G� ��f ,}�iJelrr ri.K.f`�--•- s tea` -------------- ------ Y - ._ _. FINAL INSPECTION BY-- ------------ - ---------------------•---------------- Date------- --------------------- 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 ; IRevised W-2100