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APPLICATION FOR SANITATION PERMIT Permit No. v (Complete in Duplicate) 1� Date Issued .-Lr3 A I'rcation is pp 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 AD LOCATION / '_ /""--- --""�� ---------------•--------- Owner's Na e___-__ _ __ -_. _ -- --" Address_.,. ----- -------------------------- Phone ----- Contractors Name----- ---------------"----------------------------- -------------------- • ----- __ Phone- -------------------------------- Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other Number of livingunits: ❑ J Number of bedrooms __�-" Number of baths __�_ Lot size;______p2_ �. _ Water Supply: Public system E] Community system 0 Private � Depth to Water Table 3�__ ft Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam.❑' Clay Loam ❑ Clay ❑ Adobeg( Hardpan ❑ t 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.) D Q Septic Tank: Distance from nearest well__ -=_Distance from fou dation-----/ ----#-.Material---- - ------------ No. of compartments------------f----------Size__'yd-------YSt�._Liquid depth--------- o� Disposal Field: Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line ___ _._.. • ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------"""-- Type of filter material--------------- - Yp ---"""----Depth of filter material length_--------.-_""""-- ---------- ----- ---------------- eepage Pit: Distance to nearest well______________________ Distance from foundation--------------------Distance to nearest lot line_-___.________.._ fi ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------esspool: Distance from nearest well_______________ Distance from foundation--------------------Lining material__--______._-..__-____ ❑ Size: Diameter------ -------------------------------Depth---------------------- -- Liquid Capacity, ----ga s. f Privy: Distance from nearest well__._---___--_-------------"-_ - Distance from nearest buildin ❑ Distance to nearest lot line-- ----------- ---------- ----------------------------------------- R ----------------------- - g Remodehn a,nd/or r iring escr be):-__ �� --- - ---- '4+IsYT --------------- -- ..... ..---•. ------ .- ----------------• --------------------------- i -------•--------------- -------------------------------------------------------------.-------- --------------------------------•------------------------------- -----------•-•--------------------------------- 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) ----------------------------------- - (OGvner and/or (Contractor) s (Plot plan, showing size of lot, location of syst m in relation to wells, buildings, etc., can be placed on reverse side). F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- _______________ _ - - ------`�`�-`- - - ----- DATE------ _�' 2 '�f REVIEWED BY ....... -- ------------------------------------ ----------- DATE BUILDING PERMIT ISSUED------------------------" ------------------ ------ --------------------------------------•-----------. DATE-- ---._.._..--------- -------------- Alterations and/or recommendations:_"--. _ ------------------------------------------------------------1- r ------------------------------------------ ----------------------------------------------------------------------------------------- --------------- --------------------------- -------- •---------- FINAL INSPECTION BY:_ _. L.•f-" —C ................................. Date- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California .4 ES-9--2M 10-52 Revised W-2100