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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ' ` Date Issued ____7��„�{ Applica+-ion is hereby made to the SanlJoaquin Local Health District for a permit'fo construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 JOB ADDVa OCA ON. - �\ Owner's ------ -- ----- - \�l -- ---- �--- -----0--�(-7�) /1 tG Address o _ r ------- Phone- 93_� F--- • ---- ----------- Contractor's Name--------------- _ ..----•- ---------•---------------------=------ ------- -------------------------- - - --------------------------------- Phone--------•L`-": '_.------- i Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer;Court ❑ Motel ❑ Other ❑ ,Q Number of living units:,________ Number of bedrooms „ Number of baths � ' " ---- Lot size -_--- -- -- - / - . ---------------------- •- Water Supply: Public system'❑ Community system X 'Private [] 'Depth to'Water-Table Character of soil to a depth of 3 feet: ' Sand ❑ Gravel ❑ Sandy Loam ❑ ClayLoam ❑ Clay ❑ Adobe El Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Con sfruction: Yes ❑ No ❑ TYPE OF INSTALLATION AND .SPECIFICATIONS: ` (No septic tank or cesspoolpermitted if public sewer is available within 200 feet Septic Tank: Distance from nearest wel)._/Q-4__--Distan rfr m oundation. 5.---'--___,M tenal_ - - �--_ ___ - No, of,comparfinents--------,t� Size - .r•�`r Liquid depth Capaci 4� - l fY--�f' �Ilj Disp'os I-Field-:--~`-�-Distance-from-nearest_well.- __$__1D .Distance f m-foundation____ r .___.Distance to nearest lot Iy�e Number of,,lines__________--.__. -� ft�-"• --, Length of each line--_-- ------of of trench �- -„ . ..,Type of filter material. -, ► � Depth of filter material---- -- -------------Total length----- ----------------------- gw foundation -•----• ,..w . , _Distance to nearest lot line___..-_.______.. ❑ Humber of;'pits----------------------Linin material------------- __- - -------------- Seepage it: Distance toynearest well_-- Distance from fou :Size: Diameter_________________.____.Depth_____________.--------- Cesspool: `"''.,.�. -.�.._..�.�. � -- ----- i Dis#an'ce from nearest well_________________Distance from foundation__.:-----------------Lining material - ❑ Size:Diameter------------Y`'.' Depth a - :; .. _ p - - Liquid Capacity- gals.. Privy Distance from nearest well` ------- =___ --Distance from nearest building Distance to'nearest lot'iine__ ”---.._- Remodeling and/or repairing (describe):___'____-_____._._-__.___:_._ t t ---- E = -------=--------------------•--=-•------------------------------------------------------------------•-------------------- ---- !'hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County ordinances, to la�dxules-and!,reg tionsQhe San Joaquin Local Health District. I, (Signed By --------- --------------------------- ------------------------------------------------ (Owner and/or Contractor) ( plan,showing size of lot; locatin of sysfem in relation to wells, buildings,"etc., can beleplaced on reverse side). Plot --------------------------------------------------------- 0 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED?B ' I ------.------- --------------------=--------------=----------- DATE----- --------------- REVIEWED BY -------------- ----------------- -------------- DATE "BUILDING PERMIT ISSUED - .: - -------------•-------- ... . - -------- ----------------------------------------------------------- DATE----------•--------•- Alterations and/or recommendations:______________________ --------------•-- • ----------- -------------------------------- ------------------------------------------------- ------------------------------- ----- --------------"---------- ---------- ,(� FINAL .INSPECTION BY::_�7`;T.1��—" --------------------------------- --- --------- - Date------------ ---•------- SAN JOAQUIN LOCAL HEALTH DISTRICT v/� 130 South American Street 300 West Oak Street F 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised W-2100