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APPLICATION FOR SANITATION PERMIT Permit No. ----- ..2- (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 o. 549. JOB ADDRESS A LOCATION - -- ---------------- ---- ----------------- Owner's Name------ - .. ---- --------•--------------•--------------------------- .... - - - - - - ------ ------- -- Q --- --------------- -- -- ---- Phone----------------- �------------------ Address------------- . Contractor's Name_____ ------------------- ----- Phone----------- - --------------------•-----------•----------- -- Installation will serve: Residen e Apartment House ❑ Commercial � / ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-.�__ Number of bedrooms ___'<mber of baths ---/--- Lot size -----:2_____-__ ------ - -- ----------------- ater Supply: Public system ❑ Community system ❑ Private1�cpepth to Water Table3_0-" ft. 1 Character of soil to a depth of 3 feet: Sand Grave Sandy Loam ❑ Ofeet.) Previous Application Made: Yes (] No—i' New Construction: Yes No TYPE OF INSTALLATION AND SPECIFICATIONS:(No septic tank or cesspool permitted if public sewer is available within 2 Sep Tank: Distance from nearest well-_ 6� 0----Distance from f ndat n___ No, of compartments____�j _ - J" Q Matef Size Liquid depth -------------- DisposalCepacitY $©. Field: Distance from nearest well----1.00 1-004–stance from foundation___-- ' _.-___Distance to nearest lot line_--? Number of lines--------------- ---- _Length of each line-------- 7o----------width of trench____"-. - ! Type of filler material_ _1_j CDepth of filter material-__---) - length �"---Total ------,�?----------------------- Z Seep e Pit: Distance to nearest well_____ _ "-Distance from foundation -.4t"0---_""- , anc to nearest lo# line_ �► ""-_ Number of pits___.___/___________-Lining materia 2 G - D" meter Depth � ~- C Cesspool: Distance from nearest well-----------------Distance from f un� _- .Lining material_-_---________---_-El - g~� --------------- f ' ' e: Diameter-------------- --------- - --------DQ,oth-------------------------------------------------- q d Capacity- ---- ---------- ------- y: Di _Liquid --gals. �z _ Priv �. Distance from nearest weft___ _ __-_---- from nearest building- -------------- ___ ❑ Distance to nearest lot line_. __----- " g Remodeling and/or repairing (describe}: '? ^. °• r.� 'rt /`�` rf y - _- ---------------------------------------- _. ----- -- -- - ----- - -- ---- -- ------------ ---- •- •-- ------ - --- ------ ---- - ---- 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)- ------- -------------------------------------------------- -------------------------------------(Owner and/or Contractor) BY: -------------- - ---- -------------------•----------------------------(Title)---------------------------•------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- -----"------------------------------------------------------------ __ DATE_-- --------- -------------- EVIEWED BY--------- ------------- ------------------------ - --------------------------------------- DATE--------- ----------. --- -,-P--� BUILDING PERMIT ISSUED_--_________-" "-""" --- -- --- ------- - DATE----------- ----�-,- --- Alterations and/or recommendations:_ _ _ -------------------------------------------------------------- -----"-----------------•---------------------- ---------------------------------------- ------------------------- - FINAL INSPECTION BY: Date------ -- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 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 . ReviseG 1.57 F.P.CO.