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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------ _ -2__,5 I --- --------------------------------------• --•------------------------------------------- Owner's Name _ ,ryY✓!^_ Phone - ---------- Address---------__------------- _&_ --------------------------------------•---------••---------------- ------------••------------------------------- Contractor's Name---------- ------------- Phone.---••--•----------------- - ----------- --------------------------------------------------- - Installation will serve: Residence 2--0A"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ umber of bedrooms _Z•: Number of baths I__ Lot size -----------------------=----------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑jGfavel E] San dy Loam ❑ Clay Loam ❑ Clay E] Adobe ❑ Hardpan E]Previous Application Made: Yes E] 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------------------- -----Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal - d: Distance from nearest well__ � �-___._._Distance from foundation__ � -- Distance to nearest lot line_______ Number of lines-------------- Length of each line______,__.. ��Wldth of trench___,,_______ ________________ Type of filter material_., _ �_ ---De Depth of filter material__ �� p ---;----�—:Total length---------�-�---------•--��---- Seepage Pit: Distance to nearest-well-1--_- __________Distance o fou�ation____ 1 �d_:____.Distance tP nearest �_.____ ® Dumber of pits-__.__-�____.-__-___Lining material__ ____.. _ `_Size: Diameter_ iOX �X -Depth----------------------------- Cesspool: Distance from nearest weif________________ Distance from foundation--------------------Lining material--------------------.__________-__ - ❑ Size: Diameter _,. Depth----------------------------- ---------------------Liquid Capacity--------- -:__ _..- Privy: Distance from nearest well------------------------------------- ' ____________Distance from nearest building------------------------- Distance to nearest lot line----_____.._________ r 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ (Owner and/or Contractor] ----------------------------------------- By: --- --------------------------------------(Title)------------------------------------------------------------ (Plot plan, showing size of lot, location of.,system in-relation to wells,'buildings,°etc.,'can be placed on reverse side). FOR D.EP. RTMENT USE ONLY APPLICATION ACCEPTED $Y------------ --- -- ------------------------------- --------------------- DATE__._ _ ._ ----` ---------------------- REVIEWED BY--------------------------------------------- -------------------------------------------------------------------------------- DATE - ------------------------ UILDING PERMIT ISSUED------------ ---- ------ DATE- ---- --------------- Alterations and/or recommendations_________________________________ -} ----------- FINAL INSPECTION $Y:. '`Y ' ---•----- Date------------73- '+----------------------------------------------------------- AN 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 10-52 Revised W2100