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APPLICATION FOR SANITATION PERMIT Permit No. ....�f (Complete in Duplicate) f�` -� •- - Date Issued ---�{-�_--/- Applicalion 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 Ordinance No. 549. 306 ADDRESS AND LOCATION --- --- -------------- ----------------------------------------------- Owner's Name-------- ----'-- --------- ---------------=----------------------- - Phone------------------------------------ Address..._ -- Address------------------- # ...-? . -• - Contractor's Name--- i� �----- .- :-- �`i+- _�- -------- - _ +. -- --------•----------------- Phone__ -o---• Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/____ Number of bedrooms __/___- Number of baths -_-I___ Lot size ______-Sf.7___ _.__g Water Supply: Public'system C& Community system ❑ Private ❑ Depth to Water^Table ;__.____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam L] Clay Loam Ej Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [;K 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--- a_ Material---- _ -- i----------- No. of compartments----- ------ ------Size------ _:.Liquid - -__-_- X ----- _ ___--____-_ py----- } -__------ Disposal Field: Distance from nearest we4__-`_._,--Distance from foundation___ Distance to nearest lot line____ �/++ L'okNumber of lines----____--�'--------------3 +r--Length of each line_-------- --------Width of trench.-----C, Type of:filter material--- '__/- ---__-Depth of filter-materiaL__ - '---____ TFaI length_______-./-,I'o------------------------ { Seepage Pit: Distance to nearest well_________ ________Distance from foundation--r , :--___-Distange to nearest lot line____ )i X Number.of pits.----`.-�-----------Lining materialG�_�_� 3iee: Diameter____�3------------Depth_-___02.�------------- Q Cesspool: Distance from nearest well-----------------Distance from foundation--------------------.Lining material-_.__.__________ -------------❑ Size: Diameter-------------------------------------._Depth----------- ----------------------------------------- Liquid Capacity----•-----------------------gall s. Privy: Distance from nearest well__________________ _______________.________- Distance from nearest building______.____-_-_________ f --------------- ❑¢ Distance to nearest lot Sine------ -----------------------------------------•--------------•---------•-------------.--- _________________ Remodeling and/or repairing (describe)_____ ---•------•- ------------------------•------------------------------------------------------------------------------------------------------•----------------------------------- r ------------------------------------ --------------------•------------•------------------------------------••------------•----------------------•---------------------------•------ ---------------------- I hereby certify that I have prepared this application and that the work will be don6ln accordance with San Joaquin County ordinances, State laws, and rue and regulations of .the San Joaquin Local Health District. _ r (Signed} = - 1� 3 `-------- {Owner and/or Contractor) ----------------------------------(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--------------------- --------- -- ---------------------------------------------------------- DATE------- REVIEWED BY------------------------------------------------------- -------- ------ --- DATE------ - BUILDING PERMIT ISSUED ----•-------------- ----------------------------------- DATE.._ -------- -- Alterations and/or recommendations: ------------------------•-------------------------- =•----- -- ---- ----------- ••----------------------------- ----------- --------------------•------------------------ -•----------------------------------...----------------......----••- ----------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------•-------- --------------------•------------ --------•--------------------------------- --------------------------•------ ----- FINAL INSPECTION BY:.. ---- ------------- Date-------- _ .. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California .Lodi, California Manteca, California Tracy, California ES-9-2M Ravised'W-2100