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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 Ordinance No. 549. JOB ADDRESS AND gLOCATION----— --'---�- ------------sSJ --_-- �IPJIS�t�Y� d Owner's Name 'T�= i�_ _L I� �r1-------------------- e --------------------- Phon -o64r7d_ Address-------------------------=----------- !''�"1f�-_.._.....---------------------------------•--•-•-----•---------------------••-- •---•- -•--- G i?F�_-;a ..... i'1--- -- ------ ------------------------------------ --- - - Contractor's Name__________________ . _______________ Phone:__ Installation will serve: 'Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J----- Number of bedrooms _'Number of baths ---.l__ Lot size �_____-- Water Supply:- Public system ®`Community system ❑ Private ❑ Depth to Water Table Qt. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ElClay Loam El Clay 0 Adobe �ardpan E]Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑ n —�== TYPE OF INSTALLATION AND SPECIFICATIONS: 7/ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well________________Distance from foundation--------------------Material--------------------------------------_________- 4 No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Dijgposal Field: Distance from nearest weft_________________Distance from foundation--------------------Distance to nearest lot line________-___--__- ®� Number of lines-------------------------------=--Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ See�pa,g/e�it: Distance to nearest well_ p J�1- ___Distance fr m foundation____ _______-Distanc Distance to nearest lot line...... E Number of pits----1.`______________Lining material� xA _..Size: Diameter___3_3_ Depth--------�4_.o------------------_ Cesspool: Distance from nearest well-----------_------Distance from foundation--,---------------- Lining material------------------------------------- Size: Diameter--------=-----------------------------De th-------------=-----•-----------------------------.Li Liquid Capacity ❑ � p q -----------------------------gals. Privy: Distance from nearest well _________________-------------------------------Distance from nearest building---------------------------.__-__________- ❑ Distance-to nearest lot 1rne-- ------------------------------------------------------------------- ---------------------------------------------------------------------- Remodeling and/or repairing (describe):----=----------------- ------------- ------------------------------------------- ' =--------------------------------•--•-----------•-------------------•--------•------------------------------------------------------------------------------•-•---------------------------------------- I hereby erti y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St t aws,.and rules and regulations of the San Joaquin Local Health District. Si ned _r1---- 1.�.�-----. --- ------------------------------------------------- ------- ----- Ona Contractor) (Signe g ) By:_---------------------- ----- ---- -- — ----------(Title)_ � ��' � a'------------------- (Plot plan, showing size of lot, location of syste in relation to wer�tildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ----- ------- -------------- -------------=------------------------• DATE-----------;�. REVIEWEDBY-------------------------------:------------- -------------------------------------------------------------------------------- DATE--------_------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterations and/or recommendations:------------------------------------------------------------------------------------- ------- ...........___---------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------f ______________________________________4-------------------------------.-------.----------------------------------------------.----------------.------------------------------------------------------------------------------ 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 —9-2M i ' Revi W-21 ES sed 00