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APPLICATION FOR SANITATION PERMIT Permit No. .___,� __ 1 � ,f I ^({� (Complete in Duplicate) Date Issued Applllti n is ereby �ade to the Saa Joaquin Local Health District for a permit to construct and install the work herein described. This a i ation is made in compliance with County Ordinance No. 549. JOB ADDRESS AN OCI N------------------ ---------- - -------------- ------------------------------------------------ - -- Owner's Name---- -••----•--- Ph rJ -=- ---------=----- ------ one --- Add ress___o4 ----------- ---------- ---------- ----------- -- ---------- --------------------- - --------------------------- Contractor's Name ` ------------------- ------ - �' -r = Prone.. Installation will serve: Residences Apart ant House ❑ Commercial ❑ Trailer ' ourt ❑ Motel Cher, ❑ Number of living units: Number of bedrooms _`a•4____ Number of baths /--- Lot size _--� Water Supply: Public system Community system ❑ Private❑ Depth to Water Table� t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yesg No ElFHA/VA: Yes ❑ N TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from 'nearest well_________________Distance from foundation-------------------- No. of compartments--------------------------Size-------------------------------Liquid depth--------- ----------------Capacity e l qDisposal field: Distance from.nearest well-----------------Distance from foundation--------------------Distance to nearest lot line___-_-________._ Number of lines_.----_-------------------------Length of each line------------------------------Width of trench ----_--------------------------__-- _ Type of filter material-------------------------Depth of filter material------- ------------- Total length______________________________. . .,�:_ : ------ Seep e Pit: Distance to 'nearest well _Distance from f datior ista c'e to nearest lot line.-45" Number of pits ------------Lining materiar Size: Di .......... ------ Depth r r Cesspool: Distance from nearest well------ _.,T Distance from foundation--------------------Lining material___---____-_-__________---_________- �1 r /O-"\ ❑ Size:,Diameter-=----------------- --------- ------ Depth----------------------------------------------------Liquid Capacity----------------------------gals. s - Privy: Distance from nearest well----- i__________________ ----------------Distance from nearest building------ F1 Distance to nearesit lot line__-___r_________________________________________•___ Rem•1na /or repairing (describe):--- - - -- ---- ------ - ----- --------------------------------------------------------------- (� ------------ ---------- - ------------------------ --------------------------------------------------------�------------------------ ------------------------------------------------------------- ------------ --- �--------------------------------------I k_____________.__________-_____________-_______________________________-________._____.___-._..__________-._____-________-..___- I he4b) certify that I have prepared this applicelion d that !he work will be done in accordance with San Joaquin County .ordinances, State law a d rules nd lations f the Joa Local Health District. � i f (Sign d} -------- -•- ---- ----------`/------ ------(Owner a /or Contractor] By:-;----- - -- - - -------------------------------------------------=-------------•----(Title �- ir,ee)_- '------------------ (Plot plan, 'sh'wmg ze o , oca ion of system in relation to wells, buildings, etc., can be placedon rev FOR�DEPARTMENT USE ONLY APPLICATION ACCEPTED BY'----_-- -%.R ------------------------------ ----------- DATE `_1 ------ Ll -- ----------- REVIEWED BY ----=---------------------------- - -------------------- ---------- ---------------------------------------------- DATE----------------- BUILDING PERMIT ISSUED--------------••------------------------ -- ------------------------------------------------------ DATE Alterations and/or recommendations:-_------ --------------- �_.,. •-------------------- - ��1- ---------( SI ---------P�Z-P---------ax- 4=-k� `------------`------ --- . -- ----------------•----=_-__----- --------------------------------- I ---------------- ------------------------- ----` -------------/-----•-- --- 'E----- ------- ----- .. - --------- -- ------------------`-- ----- - -------4 ---- ~7�_,FINAL INSPECTI,QN BY:.-- -- -- _ Date--------- - -- -- ----- ------------------------------------- ---------- i 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-9-2M Revised 1.57 FY.00- 1