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APPLICATION FOR SANITATION PERMIT Permit No. __S__'{_ (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 dins No 549. JOB ADDRESSZO�4� D LOBATION --- --------------------------------•------------------------------ '..: Owner's Name----------- - -- - -- ---------------------------------------------------------- - - ---------- Phone " ------------------------- -- --- -- ---- Address------1 ---. ---------------------------------------------------------------------•-------------------------------------- -- ------------------------- ----- 5 Contractor's Name-- ----------------------------- - ------------------------------------------------------------------------------------------------ Phone------------------------------ Installation will serve: Residence Apartment House C] Commercial ❑ Trailer Court ❑ Ml ❑ Other ❑ Number of living units: _L/tunity er of bedrooms .fid__ Number of baths - 1---- Lot size -1-47&11.9__ ________________________ Water Supply: Public system system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam P Clay Loam C] Clay E] Adobe �ardpan E]Previous Application Made: Yes ❑ No V New Construction: Yes Loam ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel#_________________Distance from foundation--------------------Material___-_-_.-_____________._____________________- ❑ No. of compartments------ r----Size--------------------------------Liquid depth- -- ----------------Capacity--------- ,� f---- 19, Dispos Field: Distance from nearest welIZ-19--------Distance from founciati n__ _ ___ ____ _� istance to nearest lot li Number of lines__________ v Length of each line__9sS_!� -_ Width of trench_________ Type of filter materi __. _ : ,-A e t _/ # � �> P p h of filter material_________ _ _Total length________ _ lQ ___________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line.....-_-__---_-__ ` ❑ Number of pits----------------------Lining material------.----------------Size: Diameter------------------------Depth_--.--_-------------------------- tCess opl: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________._______---___--.___...... Size: Diameter------------------ ------------------De th------------------------------ - ----------------Liquid Capacity ------gals. Privy: U Distance from nearest well-------------------------------------------------Distance from nearest building____________________________________-_--_. ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------- _--.------•--------- mg Remof /or repairing ] escribe)7 i!! --------------------------------------•---------------•----------------------------------------------... ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------I------ --------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordi ances, tate laws, and rttions f the San Joaquin Local Health District. (Signe — i.,k+�---------- -----------------------------------------------------------------------------------(Owner and/or Contractor] By:--------------------------------- ------- -------------------------------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lotstem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B --------- ------------------------------------------------------------------------- DATE REVIEWED BY---------------------- - --------------------- ----------------------------------------------------------- DATE ----------------------------------------------- ---- -- -------------------------------- BUILDINGPERMIT ISSUED------------------------------ ----------------------------------------------------------------------- DATE--------- -- - -------------------------- Alterations and/or recommendations----------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------I--------------------------------- ----------- ---------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:-------- IV -_ '_ 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 5-51 Revised W-2100