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APPLICATION FOR SANITATION PERMIT Permit No. .:__ ?.......:..... (Complete in Duplicate) ` Date Issued Applica*ion 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 JOS ADDRESS AN LOCATION Owner's Name •. ---- Phon L - .------------------ ------------ i , PAddress------------------------� ------- - hon- ,/_ fContractor's Name------- ---•• - - ------- ---------- r ------ ------------------------- Installation -- ----------------- Installation -= _ will serve: Residence g. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/_._ Number of bedrooms _,;—' Number of baths ---/__ Lot size __ __ _�t Q --------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth.to Water Table-_va ft. Character of soil to a.depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam❑ Clay ❑ Adobe Hardpan ❑ ! Previous Application Made: Yes ❑ No New Construction: Yes 0 No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well_________________Distance from foundation--------------------Materiai__.______-_._____._-__-___-________...____-____. No. of compartments------------------'--- ---Size-------------------------------Liquid depth---------------- ---------Capacity----------------------- i 7 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 matei�ia ----------------------- length__________________ ------------------------ Seepage Pit- Distance to nearest well-___-_ —------Distanc fro foun ation------I"--?___ Distance to nearest lot line- Number ineI_ [ Number of pits.._.______________Lining material�__L,_ ---------.-Size: Diameter_-__. i .....----Depth_ _a __________________ � W Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- (� ;�,. ... ._❑ Size. Diameter- --- ---- Depth -------------------- -- ----Liquid Capacity ----------------- ---gas. Privy: Distance flZm nearest t1rell_--------------------------------` _.__ __-__._Distance from nearest.building----------------- ---____________._____--- ❑ _ --- _ - ' Distance to nearest lot line _ - _ _- _ _ -_ -- - Remodeling and/or repairing (describe)------ ------------------------------------------------S� -----------------------•------------------------------..--.----_--.----------------------------------------------------- ----------------_--------------------- I hereby certify that-1 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)--.... ---- - -- ---- and/or Contractor) By:---------------- ------ ----------------------------------------------------------------------------(Title)-- ----- - ---- ----------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y --=--� ____�-------------------------------------------------- DATE--- ----•--'-�. I REVIEWEDBY--------------------------------------------- ------------r ----------------------------------------- •---------•--- DATE---------------- . ! BUILDING PERMIT ISSUED-----------------------------------------------------------------------------I------------------------ DATE_ --------------------- Aiterations and/or recommendations:----------------------------------------------------------------------------------------------------------------------•---------------------------------------- ------------------------------------------------------------------------------------------------------------------•----------•-------••---- ---------------------------------------------•-------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ----------------------------•----•-------- ------------•-• ----------------------- FINAL INSPECTION BY------------------ ---=------------- -------------- Date------------- / ------ ------- --- 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 ; Revised W-2100 1 _ ,