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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issueds / a Application 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 compliarice with County Ordinance No. 549. JOB ADDRESS AND LOCATION__!__ cS_l �� _ Owner's Name-----------------•------------•- ' --- ------------------•------------------------------------ ---• -------- •------- Urfi----•-.----- - -------=----------------- Phone Address----------------- , ---•----- --------------------------------------I--------------------------------------------- Contr actor's ------- - ontractor's Name-------•-------------•--•- -----------••-----------------------•--------------- - - ----- -- ------------------------- - _____ ___ Installation will serve: ResidenceX' Apartment House ---- Phone_.--________________ - -------------- ❑ �Commercial ❑ Trailer Court [] Motel �] Other ❑ Number of living units: -------- Number of bedrooms ----r__ Number of baths ---I---- Lot size _-..____ s Water Supply: Publics stem - ----- Y Communit system ----"------- --`-- Character of soil to a depth of 3 feet: Sand ❑ yGrav�❑PrI$and �o Depth to Water Table -------- ft. Previous Application Made: Yes I No y am ❑ Clay Loam [] Clay ❑ Adobe i] Hardpan ❑ ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: \` (No septic tank or cesspool permitted if public sewer is available within 200 fest.) Septic Tank: Distance from nearest�wefi-----------------Distance from foundation MaterialEl No. of compartments------ ------ ----------- Field; Distance from nearest well"-__---__-_-_ -.--__ __-__----------Capacity----------____-- -----Distance from foundation--------------------Distance to nearest lot line................. ❑ Number of lines____________________ - --------------Lengfh of each line------------------_ Type of filter material------------------_----Depth of filter material------"------ --_.-_-_Total Seepage Pit: length ---of french --- _= ._-- ------ -------------- -------------- ---- Distance to nearest well----------------------Distance from foundation._.._ P F --------------.Distance to nearest lot line_-_-.-_.-._..____ Number of its----------------------Lining material----_- --- _ I -- ------- Size: Diameter-------------- --------Depth---------- --- Cesspool: Distance from nearest well-----------------Distance from foundation--------------- ❑ Size: Diameter-----:#------------------------------ Depth- Lining material --- Priv #4 --------------- -----------------------------Liquid Capacity---.------------------------gals. Distance from nearest well______-__-_--__.__"-cs�- Distance from nearest buildin .� Distance to nearesfi !ot line ----------------------- _ -------_a-------------------- ------------------------------------------------ Remodeling and/or repairing (describe):_-__________________-- I ------------- --------------------------------- ------------------------------------ ------------------------ --- ---------- --.----- ------------------------------------------------- ------•------- --- --------------------�. ------------------- I hereby certify that I have pre`pered this application and that the workwill be done in accardan ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ce with San Joaquin County (Signed)---- I -- -• -------------------------------------- (Owner and/or Contractor) BY-- ------------ = ".) ` (Plot plan, showing size of lot, location`cf system in relation to wells, buildings, etc., can(bel placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------�-- - - ------------------------- ---� DATE �.. REVIEWED BY ----------------------------- ------•--------------------------------------- UILDING PERMIT ISSUED------------------------I DATE-----------•-- ---------- ------ -------------------------------- DATE ------------- ------------ Alterations and/or recommendations:___-_�-----•---•---_---- ------------------------- ---------- ------------------------------ ------•---•- --------------- ------------ -- 1 FINAL INSPECTION BY__________ l� �jj s..... Date- ----------- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT !30 South American S+nee+ 300 West Oak Street Stockton, California 132 Sycamore Street 814 North "C" Street kLadi, California Manteca, California Tracy, California —9-2M i0-sz Revised W-2100