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APPLICATION FOR SANITATION PERMIT Permit No_ ______________________ (Complete in Duplicate) �l Date Issued �" i/....... ------- 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 Ordina ce No. 549. ' c74.� JOB ADDRESS AND CATION---� 9 a - ----- ------- ---------------------------------- =-------- - ---------------------------------- LI Owner's Name--------------- -------- ---------F-l.___-- - -- --------• ----- ---- -------------------------- -------------------------- ----- ---- ' 4P o ��-- C 1 l Addres � s----------------------- -----------------------------------------------------------------------. 1----------........---� Contractor's Name-------- ---------- ------1 ,-.r_------ ------------------------------------------------------ -� --------------- Ph6 'e--- = - " ` Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. -./-- Number of bedrooms _-tL. Number of baths Lot size -----,F _. ___________________________________________ Water Supply: Public system ❑ Community'system ❑ Private 21-IDepth to Water Table _. Oft. - I Character of soil to a'dep+h of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loa ..❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No R---'New Construction: Ye ❑ No , TYPE OF INSTALLATION AND SPECIFICATIONS: otz!/ , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material ________-__-___---------.-----------!_________-�(� ❑ ' s No. of compartments--------------------------Size-------•------------------------Liquid clepth---------------- ---------Capacity----------------------- �Ll Disposal Field: Distance from nearest weft_________________Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number o{ fines Length of each line Width of trench------------------------=---------- Q Type of filter material-------------------------Depth of filter material-------------------- length___________-____-___--_-__________________ Seepag Pit: Distance to nearestell::__/Q�_r____Ditance�f�o fau ation______l_�___----D'star�ye to neares+ lot line ------------ s � C:(; Number of pits -__-._-_- --_Lining material-_____ Size: Diameter____ __ __________ Depth- _a_-__________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___._______-___-____-___._-----____._ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy; Distance from nearest well_____________________________ Distance from nearest buildingY ❑ Distance-to nearest lot line--- ------------------------------------- ----------------------------- ---------------- Remodeling and/or repairing (describe)_________________________ - -----------------------•--------------•---------------------•-----------•------••--------------------------------------------------------------------------------•----------------------------------- I hereby certify that-l have prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, State la d rules and regulations of he San Joaquin Local Health District. (Signed)------------- ►' -r'------------------------------------------------------------ ---- - 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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---------------------- DATE = ` -, REVIEWEDBY---------------------------------- - ----- --------------------------------- ------------ -------- ------------------------ DATE------ --•------------- ----------- BUILDING PERMIT ISSUED----- -----------------------•--------------• ------------------------------------------------------ DATE.----------------------------------------------------------- Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------•------------------------------ ------ ----------------------------------------------------------------------------------------- ------------------------------------------ FINAL ------1--- -------------------------------- - FINAL INSPECTION BY---------------- ----------------- D te-------------------------------------------/------------------------------- SAN -------- ---- ----------------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-9-21x1 ' Revised W-2100