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APPLICATION FOR SANITATION PERMIT Permit No. .__r�':�.�___ (Complete in.Duplicate) , Date Issued Application 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 Ordinan e No. 549. JOB ADDRESS AN OCATION__.- IrSS - --------------�- Owner's Name---.- - ------� �-------------------------- ----- 1 __ --------------------- Phone" Address..-------� ,�'--_ Contractor's Name ; ---------------•--• ----------------------------------•--------- -- Installation will serve: Residence A Phone_ e ". . partment House ❑ Commercial ❑ Trailer Court ❑ Motel E j ff hh r Number of living units: -------- Number of bedrooms 4- .Number of baths 4--- Lot size __-_ �❑ �.t ---•- .S - Water Supply: Public system Community system ❑ Private ❑ Depth to Wafer Table--------- ff. Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ r Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ 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""-- "-_---__-Distance from foundation---__----•-----_-__.Material"-__----"---" _-__--.................. No. of compartments-------------- ------ ----------------------SizeLiquid depth--------------------------Field: Distance from Weare ----Capacity____""_"""__""_"""-___ w�------- "Dista e from foundaflon�a--------Distance to nearest lo� line Number of lines.-" Lengt of eachrline__" Type of filter materi f -------Width of trench- ----- _---- --_-- -.4-�- --.- iD h of filter material---Zd-_-_--_-" Total length d-----•----------------•----- Seepage Pit: Distance to neares well ."-_Distance from foundation--------------------Distance to nearest lot line -__ ❑ Number of pits-"". ....... Hing material-" _ ------------Size: Diameter Deptk Cesspool: Distance from nearest well-----------------Distance from foundation_----"-------___.Lining material__"-__"._ _ _ Cl Size: Diameter-------------------------------------- Depth ---------------------------- ------------------------Liquid Capacity----•-----------------------gals. Privy: Distance from nearest well-_-'------------------------- __--__--_---.---Distance from nearest buildin ❑ Qistance to nearest loft line-------- " g" = ----------------------------------------------------------------------------"- Remodeling and/br repairing (describe):--___-- _ --------------- ---------- /l/r /JJ� ----------------------------------------- s- ----- - - ------ ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an regulations of the San Joaquin Local Health District. (Signed)---- ��- a • - ---��-�.�..��✓•�-ems ----------------------------------------------(Owner and/or Contractor) ------ ------------------------------------------------------ - ----- (Title (Plot plan, showing size of lot, location-of system in relation to wells, buildings, etc., can be placed o everse�side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _-" REVIEWEDBY------------------------- ------- DATE.--- ------------------------- ------------------------------------------------------- ----- ------------- - BUILDING PERMIT ISSUED" : -----_"-" _ " DATE-- .�" ..-�—'..- ------------------ �y -------------- ------- --- AI#erations and/or recommendations------------------ - - DATE- ------"----- ----------------- ----------- ------------------ ------------------- ------------------ -------------------- ## ----------------- -------------- I FINAL INSPECTION BY:"-__"-_-___ -------- ---------------- Date------ --------- ----__�' "--� - - �' ' , --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes} Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Codi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 "4