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APPLICATION FOR SANITATION PERMIT Permit No. _ --_ - / f (Complete in Duplicate) ((ff Date Issued Application is hereby made to the San Joaquin Local Health District for a permit o construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L CATI -- .................. ------ --- --- --- --------------------------------------------------- -- - ---------------------------------- Owner's Name_____- -_ Phone_ w ------------------------------------------ ------------------------------------ Address------ Contractor's Name____--_..--_-_ ------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __fO--- Number of bedrooms _/--- Number of baths __-f_ Lot size 0. - _C�' Water Supply: Public system Community system ❑ Private [] Depth to Water Table�...�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobw_� Hardpan ❑ Previous Application Made: Yes [] NOW 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 wel { ia- Distance from foundation___-- Materr No. of compartments o Size rl --s�-----------Liquid' de th--- ---Capacity - - Disposal Field: Distance from nearest well-------------- Distance from foundation---------------.----Distance to nearest lot line----------------- 0 Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------- - --------- ype of filter material-------------------------Depth of filter material-----------------------Total length-------------------------_--------------- Seep e Pit: Distance to nearest w`ell �t ^►, ._Distance f m fo daf*ion--/ ------Dist nce.tp nearest lot lin Number of pits----__--F __Lining materi I - -__Size: Diameter-_-_- '- ---------- - ---- ...� Depth „ _ Cesspool: Distance from nearest well________________Distance from foundation_____--______-_-__.Lining material__-_-___------___- 171 ------------ Size- Diameter--------------------------------------Depth-------------- ----------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------ ----- --------------------------------------Distance from nearest building-___-----___-_--------------- ---__. ElDistance to nearest lot line-------------_-_-_ -----____-----------____-__ (� Remodeling and/or repairing (describe)-------------- ¢� A -------•--------•-----•-----•--••-------------------------------------------• --------------------•--------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin County ordinances, State fig, and ru d regulations of the San Joaquin Local Health District. (Signed)________________ _ _ ------------------------------------{Owner and/or Contractor) ----- ------------------------------- By_ '------- (Title)-- ______ (Piot plan, showing size Iof, ocation of system in relation to wells, buildings, etc., can be placed on reverse si FOR PA ENT USE ONLY APPLICATION ACCEPTED BY-------------_--_____,_----. -- --- ---------------------------------------------- - DATE-------- --- '' `~ •�--. REVIEWED BY ---------------------------------- •--- DATE------ BUILDING PERMIT ISSUED--------------------------------------------------------------- -------- ------------------------------------------------------------- --- ------------• ------------- ---- DATE-- --------- -----------Alterations and/or recommendations:------------------------------ ------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------- --------- ----------------------------- - ---------- - --- •- t ------------------- Date = �c FINAL INSPECTION BY: 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 8-51 Revised W-2100