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APPLICATION FOR SANITATION PERMIT Permit No<:;;7�6____�_Y J _ U Z (Complete in Duplicate) ,6 Date Issued /�7.7../ ^ Y 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 No. 549, JOB ADDRESS D LSO TION---1 Owner's Na a---- -- ------•-- --------- --------- ----- ------ Phone = Address ' Q Contractor's Name--- ----•----------- - --- ----- ---------------------------------•-------------------------------------------=----------------------- Phone----------------------------------- Installation will serve: Residences V Apartment House ❑ Commercial ❑ Trailer Court ❑ Mp�el ❑ Oth9r ❑ F Number of living units: ____I--- umber of bedrooms -]--- Number of baths _-L_ Lot size _ _le._____________________________ Water Supply: Public system Community system Private Depth to Water Table -------- ft. Y Y ❑ ❑ p Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes [] No [( New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Q (No septic tank or cesspool permitted ' public s er is available within 200 feet.) Septic ank: Distance from nearest well____ �ista cpa fro Ifo ation__� { No. of compartments------ -------- ------- Siz -�_T_X ----Liquid depth---------a�_-----------Capacity-.-- _ - -- Dispos 'I Field: Distance from nearest well . istance from foundation-_-_ _ __ _-I__ Distance to nearest to lin .f��__.... +[ Number of lines ------ __---__ _ Length of each line-------------- Y Width of trenchll 4- 41'I , D f f Type of filter materia_ ___ .__r •epth of filter material_________ ___. length len th_______-- _ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line________________ ❑ Number of pits----------------------Lining material----------------------.Size: Diameter---------------------- Depth--------------------------------- Cesspool: Distance.from nearest well_________________Distance from foundation-------------------.Lining material-----------------..------------_•____- ..De th___ -___---_-_ :�___:_.:__ . ' Li uidTCa acit -_ .�ga [] Size: Diameter-------------------------------------- p ---- q P Y •....... ga s. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building__-._--________--___-_-_________--.__.-_. ❑ Distance to nearest lot line----------------------------------------------------------------- Remodeling and/or repairing {describe):------------------------------------------------------- ---------------------------•-•-------------------------------------------- ------•-----------------------------------------------------------•---------...--------------------------.----------•----•---------------------------------------•----------------------------------------•---------------- 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. E (Signed) - ---------------------------------------------------------------------------------------(Owner and/or Contractor) By:--- ----------------------- -------------------I----------------------------------------------------------------------(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-r" REVIEWED BY---------------------------------- ------ DATE - X BUILDINGPERMIT ISSUED------------------------------------------------------- ---------------------------------------- DATE----- - - - ------------- - Alterationsand/or recommendations:---------------------------------- --------------------------------------------------------------------------------------------------------------------------- •----------------------------------------•---------------------------- ---------------------------------------- --------------------------------------------- -------------------- FINAL INSPECTION BY':-------------- - -------- Date----------� UV - r x SAN JOAQUIN LOCAL HEALTH DISTRICT + 130 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 8-51 Revised W-2100