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APPLICATION FOR SANITATION PERMIT Permit No. A.__.-_��...... (Complete in Duplicate) Date Issued Applicata n is reby made to the San Joaquin Local Health District for a permit t;co struct and install the work herein described. This application is,made in compliance with County Ordinan No. 549. JOB,ADDRESS AND ATI _____ -- Owner's Nam - ----------- ----- -------------------------------------------- Phone---,� - ------------------- ------ Address = _..... ---•---------------------------------------------------------------------------------------- Contr"actor's Name--------------- - -- - - - ----- ------------------• ----------------------------•• - - ------------•- Phone---„�_-,�'�� Installation will serve: ResidenceX Apartm House ❑ Commercial I] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ ____ Number of bedrooms` __ Number of baths -/-__- Lot size Water Supply: Public.systeM Community ysteni ❑ Private ❑ Depth to Water Table + ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob < Hardpan E]Previous Application Made: Yes F] NXNew Construction: Yelsl�/ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: _F (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic. Ta . Distance from nearest well_______________ Distance from foundation--------------------Material _____-________._____._________._- No. of compartments----------------- ------Size------•----------------------_-Liquid depth------------------------Capacity-------------- ------ isposal F' Distance from nearest welt______-_____..._.Distance from foundation___.----- ----------Distance to nearest lot line----------------- ' Number of lines----------------------------------Length.of each line----------.--_-----_----------Width of trench.---------------------------------- a - Type of filter material-------------------------- of filter material_________.___.________Total length,____________-.... _ � - -------------------•- Seepage it: f Distance to nearest welly---Distance from f ndaticneianeter--j_______.Distance to nearest lot line__., „ / +, Number of pits---.._____________Lining material ___ _.____.Size: �`1----___.Depth.,__+--_l f�..Yl Cesspool: ”`"` Distance from nearest well-----------------Distance from foundation---.----------------Lining material__.___--___________._______._ ._ ❑ Size: Diameter----- --- --------- ;----- ----------Depth------ ----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------_-----_-------------------------------------Distance from nearest building------------------------------------------ _�._.�,-__- __________._..._._._.- �t ❑ �. - . N ' Distance to nearest lot line ------------ ---------------------------------------• --------- ------- � -- ------------- mo l d r reairindes ibe - - C --- ----- - ------- --- - ------------- -- ---- ------------ ----- --••---•---- ---- e_ 0 --------------------------------------------------•-------------------------------•---------------- IThereby certify that I have prepared +hisap lication end that the work will be done in accordance with San Joaquin County ordinances, Sfatelaws, and rul a regulat•cnsthe San Joaquin Local Health District. [Signed}-------------- ------ - ------ - ---- ------ - ------------ '-------- ------------------- ---------°------------------ -----(Owner and/or ontractor) By:----------------------- ---------------- ---- � -- ;.(Ti+le__ (Plot plan, showing size of lot, location of sys min relation to wells, buildings, etc., can be d on reverse s e)j. FOR DEPARTMENT USE ONLY 3 APPLICATION ACCEPTED BY- - -- DATE-�~----------------------------- REVIEWEDSY---------------------- ----- ---- - - ---------------------- .-----.---.-------------- ----• ------------------ DATE_ . BUILDING PERMIT ISSUED:_-_ -:-:__ - ------------- --------------------------------------------------=-----=--------•------------•-------------------------- DATE----- Alterations and/or recommendstions_-------------- ---------- C' ' 'p" -6--f-------� --------------------------- 7/ ,%;`---J_)_e -1 -------f4---------- r o__r'__ � ` --------------------f---- - ------------.... ------ ----- -- - - --------------- ---------------------•------------------------------ ---------- 4 FINAL INSPECTION BY:--------- Date-------------- -7 � - } SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M io-52 Revised W-2100