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APPLICATION FOR SANITATION PERMIT Permit No. . _�__T-_____: (Complete in Duplicate) Date Issued _ I 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 compliance with County Ordinance N 549. JOBADDRESS AND eOTIO _ _Owners Name------------ - -•s------. --- -- ---- ----- ------------------------= --------------------- --' ------------ Phone------------------------------------ Address---------------------------------------------- Name------ ------------------------------ - Phone Installation will serve: Residence partment`House ❑ Commercial ❑ Trailer Court ❑ Motelp Other 171 Number of living units: N er of bedrooms _- ___ Number of baths ---J'-- Lot size _______� !�"y___________; --------------- Water Supply: Public system Community system ❑sPrivate ❑ Depth to Water Table ----------ft. - Character of soil to a depth of 3 feet: Sand ❑ <ave I ❑ Sandy Loam ❑ �C,.l�a°� o Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes PdO" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publVsewer is available within 200 feet.) .. �. . r / s S ptic Tank: Distance from nearest wellA _ istance from fo n ation_-___------- ---.Material----- _______ ------------- Size-_- -- ___ -- -_ i d t -------- - p y__ No. of compartments___._-' Liqu . _Ca acit �- Disposal Field: Distance from nearest of__ --_______� .Distance from foundati ! pistance t nearest lot line__ ----- Number of lines__ _ __-__ Length of each line_____ _e0______ ____.Width of trench__ j * - f Type of filter material__ ✓i. De hh of flter material ��_ --____Total len Seepage Pit: Distance to nearest well__--------------------Distance from foundation--------------------Distance to nearest lot line----------- El ________ _❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth----____- --_- Cesspool: Distance from'nearest well________________Distance from foundation Lining material---------------- _ ------ El Size: Diameter--------------------------------------De th--:---.------------------ Liquid uid .Ca acit y„ S. Privy: Distance from nearest we]-------------------------------------------------Distance from nearest building-______________________________________._. ❑ Distance to nearest lot line------------------------------- -------------------- Remodeling and/or repairing (describe):__ ___ - �__ - 'rte _ �'_ ___________ ` !'�-_'mac-�---� -------- --- �-h------------------ - `��="-=----_-------------- ------- - - I ----------"--_-- - y:.. ----"�-f'�'------------ - `� -- -- --------= = =---------- ------------------- •------------•--------- ------------ - -------- � zn ------_ --------------------------- --------------------------------- - --- I hereby certify tha 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and regulations of the San Joaquin Local Health District. �I (Signed) Owner and/or Contrac ter ------------------------------------- - Title Plot Ian, showing size of lot, location of system m relation t----- -------------------------------'-----{(Title)---------------------------------------------------------------- (Plot ------------ --- ----------------------------- ( p g y o wells, buildings, etc., can be placed ori reverse side). b ' FOR EPARTMENT USE ONLY A i• APPLICATION ACCEPTED BY------ ------------------ = DATE-------- _ REVIEWEDBY ----------'-------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterationsand/or recommendations----------------------------------------------------------------------------------- -----------------------------------. -.. ---------•--------------------- ---------------------------------•-•-----------------------•---------------------------•-------------------------------------- -------------------- -- ------"---------------------------------------- •------------------ k FINAL INSPECTION BY:------------------------- ---------------------- Date--'-'----- SAN JOA4 UIN 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 8-SI Revised W-2100