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ell APPLICATION FOR SANITATION PERMIT Permit No. --------- (Complete in Duplicate) Date Applicaa-ion is hereby made to the San Joaquin Local Health District for a permit to construct and int 11 the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI N------- ��------------- - -- ------ ----- --- ------- . . Vt r Owners Name 4t = ---- - --- ----- --- ----- - ----to---------------------------- Phone--------------- Address. ,�-- -------------- ---------------------- 004Contrac:tor's Name_______ __ K; Installation will serve: Residence partment House I—] Commercial Number of baths --____-- Lot size Commercial ❑ Trailer Court ❑ Motel Other E]Number of living units: _/__ er of bede rooms _- - ---- --- - -- --------�----------------------.-- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�(d ft. Character of soil,to a depth of 3 feet: Sand ❑ ravel ❑ 5andy Lo;PNO lay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes [❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sews available within 200 feet.) Septic lfa � Distance from nearest wel eV _ lstanc frWm fpunclation__ a �/ ---------..Mater al-- -- -4 .- - -- - -------- No. of compartments--- ------------------Si e___ L? -1""' ---Liquid depth------ -----Capacity..__?_Q_CJ-- ., a~.0 00 Disposal F' d: Distance from nearest well __ _. - +stance from foundatio _ Distance to nearest lot line. .... Number of lines __. _ --_- ength of each line_____ S r j Width of trench-___ r✓ r Type of filter material- __ _` epth of lilt _�rial___._ _-� _____.Total length------- --_---------� Seepage Distance t nce oun tron____ ____--------- istance � nearest lot li Number of P .- "L9I'nA.__"_"_-- - ----------- N Cesspool: Distance from nearest well----------------_Dish fro Q --____.______.Lining material-------------------------------------- 0 Size: Diameter------------------- ------ Depth -- --------------------- -----------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well_________.________________ -------------Distance from nearest building______-.-__-___________•______.______-_-_ ❑ Distance to nearest lot Iine------------------------------ -------------------------- --- -------- ------ -------- ------ ------------------------------ 11? Remodeling and/or repairing (describe):------------ ` -------------...-_-------------------------------------------------------- ---------------- -------------------- ---------------------- ---------------------------------------- -----------------------.------------------------------------------------------------------------------------------------- --------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Statella s/an rules and regulations of the San Joa uin Local Health D' trio. (Signed).. = '' r (Owner d/or Contractor} 8' ' -•-- -/----- ----- Title (Piot 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------- r BY--------------------------- ----- --------- -- -- d3 (`.� { i ----• DATE BUILDING PERMIT ISSUED------•---------------- --------------------- ---------------------------------------------- DATE Alterations and/or recommendations--------------- -------------------------------- ------------------------------------------------- ------------------------------- ----------------------------------------------------------------------- ----------------------------------------------••------------------------------••-•-------------------------- ----••---------------------•---- -•----------------------------------•------ -------------------------------- ----------------------------------- FINAL INSPECTION BY:--------------- ---- / -� Date_ T-------------------------- 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 Revised W-2100