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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to `nssfrruuct anninstall the k herein described. This application is made in compliance.wit County Ordinance No. 549. J B ADDRESS AND L ATION:__ M_ s shF Owner's Name s_. --- -- --- - - --- --- --------- - ------------------------------ ----------------------- Address_. ------ - - - .. one ---------------- --- --- -----At --------------- Contractor Name_______ _______ -- --------- ---------------- -- -- - - - --- - - - Installation will serve: Residence Apartment House Commercial ,E] Trail Court 0 'Motel E] Other Number of living units: Number of bedrooms _J__ Number of baths __ 'Lot size _ _ rr - ---------------------- Water Supply: Public system E] Community system ❑ Privafie Depth to Water Table -------- ft. µ Character of soil to a depth of 3 feet: Sand Elan Gravel E❑ Sandy Loam ( lay Loam ❑ Cla ` y ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [�/ New Construction: Yes 9�/No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publicrsewer is available wi+hin 200 feet.) Septic ank: " 'Disfiarice fromnearesf wellDistaPcegrom foun'da ion_ - Mat ial_______ .. ---- --v�;6, No. of compartments--------_ _ r Size--- ---- Liquid dPth � Capacity_p y- 1 �. Disposal Field: Distance from nearest welli _"�" _._.Distance from foundation_ �_ Distance to nearest lot line ------------ Number Len th of each line_________ r of lines-----__---- �- o� -A - g - -�--r�----Width of trench-------=- - --- ---------- D Type of filter materia _ _1e th of filter material_______ r p --------Total length----------_,rl-Q_ -----•-----•-----•- Seepage Pit: Distance to nearest well _Distance from foundation--------------------Distance to nearest lot line___________.____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------- --------.Depth------------------------------- Cesspool: Distance from nearest well------------------Distance from foundation------------------- Lining material------------------------------------- Size: Diameter--------------------------------------Depth---•--------A---------------------------------------Liquid :Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------____-_-____.__ g_Distance from nearest building - ❑ Distance to nearest lot line________________________ ------------------------------- -------------------------------------------------------------- Remodeling and/or r pairing (describe):__--__. -_ �_ _ x� - _ - -q ---------------- --------------- ------------------- ---------- � � --------_--------•---•------------- --------------- ---- - ---- -- ------ ------ ----- ------------ ------ - - -- ------------ ---- ----- ------ --•- ----- ---------- I hereby certify that I have .prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of +he San Joaquin Local Health District. (Signed)-------- 'L s - - ------(Owner and/or Contracto Sy:--------- -------------•---------------•-------------------------------------------------------------------------------------------(Title)------------------------------------ (Plo-fplan, showing size of]of, Foca+ion of system in relation to wells, buildings, etc.; can be placed oa-reverse side):'-=-_ --- ` FOR DEPARTMENT USE ONLY APPLICATION I - ACCEPTED BY BY -- ------- --- ----------------------------- ---------------------------------------- DATE_ REVIEWED BUILDING PERMIT ISSUED------------- ---------- DATE---- -------- --- - -------- ------------- ------------ ---------- DAT.E---------------�`------------•-=-------------------- - Alterations and/or recommendations:_-_-- _ ------------------------------------------- - ------ ---- --------------------------------------------------------•---- ---------------------- ----------------------------------------------- FINAL INSPECTION BY:------- -_- --------------- Date--------- ----- --------------- `.-- - ----------- 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 Fracy, California ES-9-2M 5-51 Revised W-2100 � I