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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicafel 1 Date Issued ----------- A _-- !-- Applica{ion is hereby made to the San Joaquin Local Health District for pper ' construct dinstall the work herein described. Thisapplication is made in compliance with County Ordinance No 49. JOB ADDRESS AND.L ATI -;------ ---- -----------r-- ---- - - ----- •. ---------------------------------- - --------- Owner's ---------------------- -- - Owner's Name -- - - - -- ----------- ---- . ................. Phone Address ------------ -- -- ------•--� • ----- ------ --------------------------------------•--- ------_---------_-1 Contractor s Name -� --------•-•------ Phone. '..... --------------- - Installation will serve: Residence —Apartment House E] Commercial E] Trailer Court ❑ 'Motel E'] Other L]Number of living units: _ _-____ Number of bedrooms _.2— Number of baths_-_ - Lot size ____l _-----___;------- Wafer Supply: Public system�Community system E] Private E] Depth to"Water Tablel/_ ft. Character of soil to a depth_ of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan [❑ Previous Application Made: Yes ❑ Nov New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permifted if public sewer is available within 200 feet.). +isposal Ta : Distance from nearest well_________________Distance from foundation--------------------Material ' No. of compartments--------------------------Size----------------- -----:--Liquid depth--------------------------Capacity----------------------- Fiel Distance from nearest well_________________Distance from foundation---------------_____Distance to nearest lot line_.---------- Nu M- ber -________Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------------__-- t Type of filter material-------------------------Depth' of filter"material------------------------Total length-----------------------------------_------ Xepa t: Distance to nearest well/'{ ------Distance f m fo dation Q_-+_._..D' tante to nearest lot line_ _ -------- Number --- Number of pits__ _______________Lining material .__ _._ _ t__Size: iameter____„7_�------..____Depth_____.�_____________ ol: Distance from nearest well____-------------Distance from-foundation__--_.--------------Lining material----------------------__.__________- ❑ Size: Diameter-- I--------------------------------Depth----------------------------------------------------Liquid Capacity- --•---------------------..gals. Privy: r Distance from nearest well._____________ _---------Distance from nearest building--------------------____-______---------. ❑: _ Distance to nearest lot line F - --------- --- Remodeling and/or repairing (describe):-- ----- -- ------- --� --- - --- ----- --- n 5 ' --•--•-----:------------- --•-------- ;---------------------I-------_-.------------------------ ----------•-•-•----------•---••------------•---------•---------------------------•---- •------------------ ------------- ---------•----------------•-- --••---------------------------•------------------•--••------•••--------------•--••------------------------------------------------------------------------•--------- --------------------- .; i I -hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws,`a ul and regulations of the San Joaquin Local Health District. (Signed}------- --- ---- - --------------------------------------------- ------"------------------------------------------------- (Owner and/or Contractor) -'«. f BY? 0 I - (Tiff@} r (Plot plan, showi size of lot, location of system in relation to wells, buildings, etc., can be placed reverse side). 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- - - --- --------------- ----------------- ------------ --------- DATE--------------- 0 BY-------------------------------------- ! DATE ---•---•--- ----- -- ------------------------------------------------- ---- ----------- -------------- BUILDING PERMIT ISSUED----------------`--------C)----------------------------------------------------------------------- DATE:------------------ - - Alterations and/or recommendations:------------------------------------------------------------------------------------------------- ---•------------------------------------------------------- -------------- ---------------------------•----'------ -- �•J-�---�--�- .----------------------- . - l` dc2G. r.r ----/_ . ---= ----- •-•--- - --- --------------- Q -----------------------------------------------------------------------• - -- - ='.. �y� A •------ - -------��--'--------- I --------------� --- --- --------------/-- �r -•'-- ----- FINAL i� = FINAL-INSPECTION BY:---- Date---------------- � r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Menfeca, California Tracy, California ES-9--2M Revised W-2100