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APPLICATION FOR SANITATION PERMIT Permit Mq. j— x !- (Complete in Duplicate) pp r Date Issued (/ T 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 LOCATION--------- ------------------------------------------------- Owner's Name------ Phone.-_ _V7 ---- Address.._---- -----------_ _ - ------- -•--------------------------- --- Contractor's Name-----------_-------------•- --------�,__________~------ -- -- -------------- ----------- Phone---- ------- --/,Z.a� Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: ---/_ Number of bedrooms -o;-_ Number of baths _1-_ Lot size ___�:_ _� -- ----�--��----fes-------------------- Water Supply: Public system ❑ Community system ❑ Private'K Depth to Water Table Z ft. i Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ Noo TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) #ep,ficlanl: Distance from nearest well_________________Distance from foundation-------------------Material----_-------------------- ____ No. of compartments Size- Liquid depth ------------Capacity---------- ---------- W Disposa3 Field: Distance from nearest well----- ®-'Distance from foundation__/4 -_-__.Distance to nearest lot line__ Q_----� i Number o"i lines------------ __- - --. --- " ° ----------------- i OToal length------ --- _----------- Type orfilter material- A ------------- goeacne------ Width of trench-- PA Depth of filter material_ . ---_ Seepage Pit: Distance to nearest well----- oe-----Distance from foundation____ � Distance to nearest lot line-_-.� ---_ Number of pits_______ _----------Linin g materiaL_�_-Size: Diameter------!*"o--------Depth_____ ��--- Cesspool: Distance from nearest well----------------- from foundation----- --------------Lining material__-__---________._.____--_-__-______- Size: Diameter------------------ -- p --=--------------- ---�'��-'�-� -=Liquid- Capac fy_ --------------------------gals Privy: Distance from nearest tirell___-___________ ---------------------------------Distance from nearest building ❑ Distance to nearest lot line----------------------- ------------------------ Remodelin and/or repairing (describe):___ � �� -- 2• , r ------ ------------------•------ ---------•----------------------------------------------------------------- - ---------------------------- ------------------ -------------------------------------------------------------------------------------•----------•-------------------------------------------------------------------------------- --------- -------- I 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 and regulations of the San Joaquin Local Health District. (Signed) ------- ------ - ----- ---fl----- ,Owner and/or Contractor) r SY� - --------------- -- •-----------------------------------------------(Title) `�"S/ 27_ ------ (Piot plan, showing size of tot, location of sys m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------ ------------------------------------___ __ _--- ------ - DATE ------------------ ------ -- - -- -------------------------- REVIEWED BY ------- -------------------------------------------------------------------------- ---- DATE__f BUILDING PERMIT ISSUED------------------------ __ DATE____-- 4------------ ----------------------------------- 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 Tracy, California ES-9-2M l0-52 Revised W-2100