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APPLICATION FOR SANITATION PERMIT Permit No. . (Complete in Duplicate) Date lssued , Application is hereby made to the San Joaquin Locai Health District for a permit to construct and install wor�er in©esscribed. rThis application is made in compliance with County Ordinance No. 549. iln. .:. ._ C3B AD KESS AND LO fON__ - Owner's Name_____________ V --------"---------------- Phone Address . Q - 4 - --------- ------ _ _ _ Phone---- -------------- Contractor's Name-------------------I---------------------------------- --------------------------------------------------- � Installation will serve: Residence eApartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ___ Number of bedrooms _- Lot -- Num _ ber of baths size - -__ ___ ___ _ ----------- w Water Supply: Public system ❑ . Community system '❑ `Private Depth to Water Table 7�ft. Character of soil to a depth of 3 feet: Sand [Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application-M6-de-Y6—s [1—N0- [V !New Construction: Yes -No�❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public saver is available within 200 feet.) t � Septic Tagk-. Distance from nearest well---�_-g__.Distance from foundation---/-________-Mat riaL_______ No. of compartments-------- 2--nn -Size--------------------------------Liquid depth---_- _-- Capacity_-_- . __.Distance to nearest lot line.---/ Disposal Field: Distance from nearest we+l___._ Distance from foundati n__ f 2 j T �-- --- d� Number of lines_____________FT __-______��Length of each line___ ________ __.Width of trench-----Z,:---j Type of filter material-y --------'Depth of filter material__-_-- Total length----------------! - Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------- El Number of pits---------•-----------_Lining material-----------------------Size: Diameter------------------------Depth-------------------- Cesspool- ------Cesspool: Distance from nearest well_________________Distance from foundation-----------__.__.---Lining materia!-----------------------------._______ ❑ Size: Diameter-------------------------------- -----De Depth --- p Liquid capacity gels Privy; Distance from nearest we7i_�"" -------------------------- - -------' Di"stance from nearesfi building--` -_- ❑ Distance to nearest lot line------------------ - •-----•--------- _-- -------•-----_-- --------------------------------------- Remodeling and/or repairing (describe)----------------------------------------------------------------- �t ----------------------------------------------------------------•-----------------------------------------------------------------------------------------------------------------------------•--•------------------ 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 re ulations of the San Joaquin Local Health District. r , ._ (Signed).._ 4----1!2�-)�- ---- ....... - - (Owner:and/c ;►aiectoif BY- - ---------------------------------------------------------------- ----- -----------(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---------/-- a— REVIEWEDBY. -------------------------------- • -------------------------------------------------------- DATE -- -------------------------------- BUILDING PERMIT ISSUED--•---------------------------------------------------------- --------------------------------------- DATE -----------------------Alterations and/or recommendations:._.____-- --------------------------------------------------------------- - -----------•--------------------------------- -------- ----------------------- - ----- - -- -- -------------- ---------------------------------- C / �/ � �� FINAL INSPECTION BY--- -------- ------ Date / SAN JOAQUIN LOCAL HEALTH DISTRICT { 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 r' �