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APPLICATION FOR SANITATION PERMIT Permit No. _-- _- - - --- (Complete in,Duplicate) Date Issued - --1 -S3 Application is hereby made to the San Joaquin Local Health District far a permit to construct and install the work herein described. This application is made in compliance with County Ordii No. 549. // )�J ---- JOB ADDRESS AND LQOATION,--- = Phone---��---- Owner's Name-----.- -- =' ------------------------------- ----------•------------------------- ---•------------------•----- Address--------- ------------- J' --•w ------------------------------------------------------------ Phone----_- --- Gontracfor s Name_--.--.- / -.-- ----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms=- Number of baths -- Lot size Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabled-sft. Clay ❑ Aclobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [I Previous Application Made: Yes E] No New Construction- Yes E] Noo I TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ----------- ---------- ------------ ------� Septic Tank: Distance from nearest well-----------------Distance from foundation___-----.----_-__- Material-. Capacity--------- i No. of compartments--------------------------Size------•---------- ------------- Liquid depth r ' es�' . _---_-Distance from foundation---______----._-.Distance to nearest lot kine----------------- Disposal FieldDistance from nearest well-___---___ -Length of each line------------------------------Width of trench--------------------------=-------- _ ,{�� i�/ umber of lines g / Type of filter material-------------------------Depth of filter material-------------�------Total length---------------------------- J $eepag Pit: Distance to nearest well 1�_--_Distance fr, m four;'da#ion___ ----_-_i__.Distance rto nearest lot line -_.-- Linin material �A-Size: Diameter--- .�--- -----.Depth------------------------ Number of pits----- /--------- g � '"f 1 - Cesspool: Distance from nearest well--------------_.Distance from foundation----------.--------- Lining material__------------------------------els. ❑ Size: Diameter------------------------------ -------Depth------------------------------ -- .------------- -------Liquid Capacity---------- ------------9 Privy: Distance from nearest well--------------------------------------------------Distance.from nearest building---------------------------- ❑ -- ^--------------------------------------------------------------------------- Distance to nearest lot line...__,_--_ _ -- _ -,-�---------------�------- remodeling and/or repairing {describe)-------------- -- �!-_- 1�;-?-, - r :==-------------------------------------•-------------- ---------------------------------------------------- -------------------------------------------------------------------------------------------- I•-------------------------------- ------------------- ! hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsrand rules pKiT regulations of the San Joaquin Local ealth District. �� ----- -= ----------------------------- (Signed) - (Owner F and/or Contractor) ----------------Title--------- -(Plot plan.plan, showing size of lot, location of sys e in/elation to -Wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACC TED BY-------------------------------------- -------------------------------------- DATE- APPLICATION ------------------------------------------------ YDATE----------------------------------------------- BUILDINGPERMIT ISSUED_----------- ---------------------------------------------------------- M ---_--•-------------•_---_------------------------------- Alterations and/or recommenda+ions------------------------------------------------ --------------------------------------------------- - I --- -----------------•-------------------------------------------------- --------------------------------------- ------------•---------------- --------------------------------------------------------------------------------- ---.- ----- ------------------------------------- --------------------------- --------------------------- ' r Date--------L----- ---- - ---- ----.-J----I-- FINAL INSPECTION BY:-__---.-- - � 'r--- ----:------ SAN JOAQUIN LOCAL HEALTH DISTRICT 138 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street pLodi, California Manteca, California Tracy, California Stockton, California F ES-9-2M B-51 Revised W-2100