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N h� Permit No. APPLICATION FOR SANITATION PERMIT .... ---•-�' (Complete in Duplicate) Date Issued _3-----t°--a�- Applica+ion 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. r F r , ------------------ JOB ADDRESS AND LOCATION---------- --.---- ----------------------------------------------------- --------- a r :-. - Phone ------------------------------------ Owner's Name -----• ( - - = - ---------------------------- Address---------- Phone Contractor's Name-•-- _;;_C --- Installation will serve: 'Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-j____ Number of bedrooms Number of baths _/-__- Lot size _6-d------- --------------------- Water Water Supply: PublicssystemCammunity system❑ -Private F-1Depthto Water Table--_25_0 ft.' Character of soil to a deptk of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe Rt,Hardpan ❑ l3 Previous Application Made: Yes ElNo R�__ New Construction: Yes K No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank:or cesspool permitted if public sewer is available within 200 feet.) Septic Tan istance from nearest well------.----------Distance from foundation--------------------Material____-_'__.__--_.____._____-_____.--------___-. ❑ compartments------------ ----- - ------Liquid depth------------- --Capacity Size p ty-------------------- Disposal Field: Distance from nearest well----__._.____--Distance from foundation_________________.Distance to nearest lot line.__._______._..._ ❑ er of lines-----=----------------- ---------Length of each line-------------------------------Wiclth of trench.---------------------------------- TypeOT-filter material-------------- ----------Depth of filter material-----------------------Total length---------------_-------------------------- �. . .:,� Seepage Pit: Distance to nearest well_. 6 - Distance from foundation___. __?.-.Distance'' nearest lot line__._.3_4- Nuimber of pits------- ------------Lining material--- e: Diameter--___ `'-----Depth-_---'' _---- �� -- Cesspool: Distance_from nearest well----------------'Distance from foundation.....:..............Lining materiel___;,___._.___- Size: Diameter- -------------------------I---------Depth-----------------------:-----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___.__-- ----------------------------------------Distance from nearest building__---------------------------------------- ., -_: _ - ----- ❑ �, Distance'to nearest lot'line-------- -- =---- --------•-------- Remodeling and/or repairing (describe)----------------- - ---- ----------------------•- -------------------------------------------- ----------------- ----------- ------------------------------------- -- .. ----------------------------------- =e • t --------------------------- --------------------------------------•-----•-----:--------------------------------------- );hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County, ordinances, Sta , and rules and regulations of-the San Joaquin Local Health District. (Signed}_ _ { I ] ( wrier and/or Contractor) ---- = Tit - ----------------------- ------ BY [�L -------------------------- e r (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 3 : .._ :. REVIEWEDBY---------------------------- --------- ------------ DATE--------- ----------------- ------------------------- BUILDING PERMIT ISSUED--------------------------------- ------ DATE-------------------•-----------------------------•----- Alterations and/or recommendations-------------------- ------- --------------------- .--------•--------------•----•-----------------------•---._...__--------------------- A S, --- ------------------------------------------------------------••--•------•----...----._.. ---------- ----------- -- ----- - -------- -------- -- ---------- FINAL INSPECTION-BY:.._..:_ ----- Date__.. _... 5- ------- SA ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M ; ' Revised W-2100