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APPLICATION FOR SANITATION PERMIT Permit Na-.3 4 (Complete in Duplicate) �J Date Issued - - - ---•-------- Application is hereby made to the San Joaquin-Local Health District for a permit to constrruct and�sall the work herein descri ed. This application is made in complian a with Count Ordinance No. 549. 4m _ O'B ADDRESS AND C ION '--.--- �_._ • - ----------------------------- - - -- - Owner's Name---. __-._ ._► --`- . Phone----------- ---------------- ---- Address ��` . ..--- i Contractor's Name----------•--------- •---- ------ Phone = -" Installation will serve: Residence partment House ❑- Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- ---- Number of bedrooms -%I)--- Number of baths -_. - Lot size ---------4_____ 'r Wafer Supply: Public system ❑ Community system ❑ Private Depth to Water Table opll�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [ Clay ❑ Adobe ❑ Hardpan [] Previous Application Made: Yes ❑ No 0( New Construction: Yes* No ❑ r 1 TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest ---Distance from foundation---- 1_n ---- _.Maters ------ .-_--.--__------ - _ -- No. of compartments-----.:?-" Size_5_";t/Ox�Liquid depth--------- ------_.Capacity_-/-S_0i_6__- Disp s IField: Distance from nearest eii- -_Distance from foundation_._'"------.Distance to nearest lot !i e-__� Number or lines---------- ,.- _ gth of each line_-_-----_� ��_Width of trench.. -, -�__________________ �Jv e` th of filter material__--�-$-------- c Type of filter material------ ---_ - Total len Seep Distance to .nearest w istan moom f¢ __ fia nce +nearest,Iot lin {r m ria Number of pits__-:-.- -: -"- � p•stance from � C spool: Distance from nearest weII ------------- oundation- ___----..Lining material-__---.-------.-.- - ❑ Size; Diameter--------- t Depth - ------ Li ui r . �.,r� �::...�_ �. 9 d Capaci�-_; ---gals. Privy: Distance from`nearest,well------------------------------------------------- -Distance from nearest building ❑ Distance to nearest lot line_----------- _. - - -------------------------------------------------- Remodeling and/or repairing (describe):'-_- , _ , ------------ --------- ------------------------------------------------------------•-------------- --•-------••-------------------------------------------------------------------------------------------_---..-•---------..------------ I hereby certify that I have prepared f ' ap ication and that the work will be done in accordance with San Joaquin County ordinances, Sfa ws, and rules and regu n f the San Joaquin Local Health District, } (Signed) ----- ---- ----- ( / --^--- - - -------------- - ------- ------------ ---------------------------- Owner 'and/or Contractor d Plot Ian, showing -- of lot, location of system m relaf------------------------- -- - ---- ------ -----(T'tle)-------------------------------------•------ ------------------- ----- ----- ( P 9 on to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------------------------------------•-•------------- . DATE ---------- REVIEWED BY - x-_ - ------ -------------- DATE-------- / BUILDING PERMIT ISSUED -------------------------•- DATE ------------------------ Alterations -- ------ and/or recommendations--------------------------- I --------------------------------------•---------------- -------------------- r ----•----------------------•----- ------------------- ------ ------- ----- ------------- --------- -----------------------------------•------------ -- -------------- ---•• - ------ -----------------------------------------------------r------------------------------------•--- FINAL INSPECTION BY: --------- ---�- /� Date t�� ------------------- ------------------------------------------------------- SAN 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-4-2M 10-52 Revised W-2100