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# A�PPLCATION FOR SANITATION PERMIT Permit No. __-.--/________.__._-_ - 5 Z— — (Complete in Duplicate) GG J/ Date Issued __f _-- - -_-- 1i Application is hereby made to the San Joaquin Local Health.District for a permit to construct and install the work herein described. I This application is made in compliance with Cou Ordinance No. 549. �+ JOS ADDRESS AND LOCATI -.-- ______ __-___ ____ r`nr a -- —----------------------------------------------- ------------- t Owner's Name-------------- - ------- --- -- --------------- Phone-- __ Address---------------------1-- ----- ...ter- ---- ----------- ------ Contractor's Name _ °_ • hone_- Installation will serve: Residence ❑ Apa tment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other `❑ Number of living units: __�____ er of bedrooms --- Number of baths _/--_ Lot size ------ Water Supply: Public system Community system ❑ Private ❑. Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan Distance from nearest well-----------------Distance from foundation-------------------_Materiai__________-_-------_---_-- ____________________- �Fk4�oj% No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- �� Disp .0,Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line----------------- {�.'� ❑�'�Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------------------------. 7ype of filter material-------------------------Depth of filter material----------------------- length-----__-----_-.--------------------.------ ( 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_______-____________________________ (A E]. _ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building------------------ ____ ______- Distance to nearest lot line ---- ------------------------------- ------------- --------------�1110 ��... it � Remodeling and/or repairing (describe]------- ------ --- -- ----------- � -----------•- --------•-----------------------•----•------- --------------------------------------------------------------•-----•------•----------------- ------------------------------------------------------------._.-..-•--------------------------------------------------•----- ----------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances; State laws, and rules a regulations of the SapJoaquin Local Healt District. �. — Signed] V� ---t- ---- -C`-____-_--_-- * "'°5/+'"If,.� __(Ow / Contractor) By: - ---------------- - (Title) (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc.,,can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ DATE F REVIEWEDBY------------------------------- ----------:---- -----.------------------------------------------- ------------ ------ DATE--- ----------------•------ -----•------ ------ BUILDINGPERMIT ISSUED.- }-------------------------------------------------•-------------------------- DATE ---------------------------------------------------- Alterationsand/or recommendations----------- ---------------------------------------------------------------------------------------------------------------------------•---------------------- - -------------------------------------------------------------------------------------------------i-----•-------------------------------------= --------------------------- ---------------------------------_r_--------------- FINALINSPECTION BY:--------- ------------------------------------- Date---.---- _----------------------------------------------- k 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-8-51 -Revised W-2100