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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) , t", - Date Issued Applica{ion is hereby made to the San Joaquin Local Health District for a permit to c ruct en install wor rein ,ribed. This application is made in complian e with County Ordinance.No„549.- - � I � JOB ADDRESS A D L CATIQN_-__-• - - j_-_---_-- - - -•-------------- Owner's - -------- ----- Address i �m ----- ---------- r -•-------------------------- -=------------------------------------ -•----- Contractor's Name----- i-.. Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other .❑ Number of living units: _______ Number of bedrooms__ :;Number �� # : baths ---- --- Lot,size -A-_._--• - Water Supply:I • Public system '' 3 Communit s stem ------------------- Yy Y ❑ Private RF Depth to'Water Table -------- ff." " Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Ej Clay Loam ❑ .,Clay ❑ Adobe Hardpan E7 Previous Application Made: Yes ❑ Nto L New Construction: Yes I ❑ e a TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within-200 feet.. Septic Tank: Distance from nearest well______._----_--_ 4 -- - Distance from foundation_----------••--_•--.Mat erial--------------- --------------------------------. ❑ No. of compartments-------------- ------Size------------------------------..Liquid depth- -Capacity Disposal Field: Distance from nearest well-_____-__------- : . Distance from foundation_____________1 .Distance to nearest lot line---------- ----------- . : Yp_..�...., ---'-------;�----------- --Length of each line----------------- or -----•-�---_.Width of trench-----------•---•�------=---------- rI__----}-"--°--- `'----tDepth of filter material--------------=--4----Total length-----------•---•----- Number o rues_____-___ p g ateria e r filter m�., E. ,' ,�-•-w,,..-...,,.. _I •: r. ! M�� ... --------------------� Seepage a Pit: lDumabere of r is test well --....,_,,. ' q� r ( Drstance from foundation_ _______ _+.Distance to nearest lot line__ •___.________ p ----- --------Lining,material. = Size: Dia ie�- __ nn - Cesspo Distance from nearest welf "i' ' ' Distance from foundationinrng material-. Size: Diameter-----_-- 1 i V ---_ ----Depth--:_------------ _--•-==- ----Li Liquid Capacity Y ► P tY > 4 � � .. + -----gals. Privy: Distance from nearest well- =-------•---- __----- - : , - ___- __ _Distance from nearest building_______________`--:_ Distance to noarest lot'li a--- _ , - - - ------------- Remodeling and/or repair i )._ng (describe -- r = - - ------------------- 1;hereby _____ - ' M •.. ___ -------------- --------------- -----------------______- _____________-_-______ ..._- -------------------------•--:.. I certify Ghat l have prepared-this applicafion-andir Ghat the work will,be done in7accordance with San-Joaquin County ordinances, State laws; and rules and regulations of the San Joaquin Local Health District.' r ' (Signed).:: t ------------------- (Owner and/or Contractor) 8Y� ---------------------•------- ---- ----- -(Title)---------- - ¢------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,` etc., can:be placed on reverse side)! + FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------•--------- �--•-------------DATES- s '.i° ---� REVIEWED BY---=-------------------------- - - --•-----:-----------------------------j--------- - -•---- ----- BUILDING PERMIT_ ISSUED--------------------`__-- - ATS__ -------------------------- ------------------------- -------------------------------------------------------------- --- DATE.._-"~" , A aerations and/or recommendations: ---------------- x?f4 = r ----------- •----- •---- ------ _ ______ `___._._---'.----.-.--_-----------..- -------------------------- FINAL INSPECTION � --------------••'--------- �� ,`,7 ------- BY..- - - �.r - 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 Revised W-2100