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APPLICATION FOR SANITATION PERMIT Permit No. ---V-tk- (Complete in Duplicate) Date Issued 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 No. 549. ; JOB ADDRESS AND LO TION----- _ -,, --- --------------------------------------------------------------- Name------ r-------- - --------------------------------------- Owner's Phone_ = �� Address----- - ---------- 17) -------------��Co ntractor's Name ` Phone/ J� - ----------------------------- - - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ ,Other ❑ Number of living units: �__-- Number of bedrooms _/-__ Number of baths --f-- _ Lot size ____ ®- - �� ---- i Water Supply: Public systemCommunity system ElPrivate ❑ � Depth to Water Tabla� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobA<Hardpan ❑ Previous Application Made: Yes ❑ NNew Construction: Yes ElN� TYPE OF INSTALLATION AND SPECIFICATIONS: (No(No septic tank or cesspool permitted if public sewer is available within 200 feet.) Leptic Tank: Distance from nearest well-----------------Distance from foundation______----__-_-__--Material____-___----_-____-_-__.___--_-.______---_______. // tNo. of compartments---------- ------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Dis'pCo7sal.FFiie-ld. . Distance from nearest well_________________.Distance from foundation----____--___-_---_-Distance to nearest lot line_._._____--....__ } 71 Number of lines-----------------------------------Length of each line------- ----------------------Width of trench-------------------•--------------- 1 y Type of filter material____________________-- epth of filter materia l--_-___-----____/....Total length----._______-__-----..________.�__-/.-- v Seepa a Pit: Distance to nearest well- Distance f m fo dation_-_� .___. __.Dista ce to nearest lot line---- ------- Seep;oe Pit: Distance to nearest Distance f m fo dati itsf b Number of pits-------/-_--------- ning material -Size: Diameter---- ---------------Depth--____--f,,er___------------ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material --_________-__-____--_.____-_-- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------.---------------------------------------Distance from nearest building--------------._______--.-_-----.______--. ❑ Diistance to nearest lot line------ ---- -- --------------------------- •-------------------- Remodeling and/or repairing (describe):--------------- °i ----------------------------------------------------=------------- .. F --------------- ^------------------ .------------------------------- ----------• ---------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stateplad-rules a re ations of the San Joaquin Local Health District.Si ned --------------------------------------------------------(Owner and/or Contractor) $ Lei--- ------------- -----------------(Title)-�- �side)- (Plot - - ---- -plan, showino , Iocation of system in relation to wells, buildings, etc., can be place on reverse FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ ------------------------------------------------------------------ DATE_ x ---------------------------------------- ------------------------- REVIEWEDBY------------------------------- - --- - ---- ----------------------------------- ------- ------------------------------- ---- DATE----5�, BUILDINGPERMIT ISSUED--------------- ---------------- --------------------------------------------------------------------- DATE--------P;A----------------------------------------------- Alterations and/or recommendations------------------------- ------l'----------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------ -------------------------------------------------------------------- e - Date-- fQ ---------------------------------------------- FINAL INSPECTION BY: 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 8-9-2M 9-51 Revised W-2100