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APPLICATION FOR SANITATION PERMIT Permit No. . <br /> (Complete in Duplicate) <br /> Date lssued , <br /> Application is hereby made to the San Joaquin Locai Health District for a permit to construct and install wor�er in©esscribed. <br /> rThis application is made in compliance with County Ordinance No. 549. <br /> iln. .:. ._ <br /> C3B AD RESS AND LO fON__ - <br /> Owner's Name_____________ V <br /> --------"---------------- Phone <br /> Address . Q - 4 <br /> - --------- ------ _ _ _ _ <br /> -------------------------------------------- -- Phone Name-------------------I---------------------------------- � <br /> Installation will serve: Residence eApartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ <br /> Number of living units: ___ Number of bedrooms _- Lot <br /> -- Num _ <br /> ber of baths size --------�_____ __ ___ ___ _ ----------- <br /> w Water Supply: Public system ❑ . Community system '❑ `Private Depth to Water Table 7�ft. <br /> Character of soil to a depth of 3 feet: Sand [Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Applic9tion-M6-de:Y6—s ❑"No <br /> !New Construction: Yes -No�❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public saver is available within 200 feet.) <br /> t � <br /> Septic Tagk-. Distance from nearest well---�_-g__.Distance from foundation---/-________-Mat riaL_______ <br /> No. of compartments-------- _ n -Size--------------------------------Liquid depth---_- _-- Capacity_-_- <br /> . __.Distance to nearest lot line____ __________ <br /> Disposal Field: Distance from nearest we+l___._ Distance from foundati n__ f 2 <br /> j T �-- --- <br /> d� Number of lines_____________FT ----------'Depth of filter material__-_-- Total length----------------! - <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------- <br /> El Number of pits---------•-----------_Lining material-----------------------Size: Diameter------------------------Depth-------------------- <br /> Cesspool- Distance from nearest well_________________Distance from foundation-----------__.__.---Lining materia!-----------------------------._______ <br /> ❑ Size: Diameter------- ---------- -------- ----De Depth --- <br /> p Liquid capacity gels <br /> Privy; Distance from nearest we7i_�"" <br /> -------------------------- - -------' Di"stance from nearesfi building--` -_- <br /> ❑ Distance to nearest lot line------------------ <br /> - •-----•--------- _-- -------•-----_-- <br /> --------------------------------------- <br /> Remodeling and/or repairing (describe)----------------------------------- ---------------------------- �t <br /> ----------------------------------------------------------------•-----------------------------------------------------------------------------------------------------------------------------•--•------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District. <br /> r , <br />._ (Signed).._ 4----1!2�-­)�- ---- ....... - - (Owner:and/c ;►aiectoif <br /> BY- - ---------------------------------------------------------------- ----- -----------(Title)-------------------------------------------------------- <br /> (Plot plan.-showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- - - ----------- ------- ----- --- DATE <br /> ---------/-- a— <br /> REVIEWEDBY. -------------------------------- • -------------------------------------------------------- DATE <br /> -- -------------------------------- <br /> BUILDING PERMIT ISSUED--•---------------------------------------------------------- ------- -------- DATE <br /> -----------------------Alterations and/or recommendations:._.____-- --------------------------------------------------------------- <br /> - -----------•--------------------------------- -------- ----------------------- - ----- <br /> - -- -- -------------- ---------------------------------- <br /> C / �/ � �� <br /> FINAL INSPECTION BY--- -------- ------ Date �. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br /> r` � <br />