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APPLICATION FOR SANITATION PERMIT Permit No. _•--- (Complete in Duplicate) Date Issued __-. r _b - Applica+ion is hereby made to the San Joaquin Local Health District for a pg,rmit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN LOCAT Owner's Name Phone.__._. ---- Addre Contractor's Name--- _ -------------------------------•------ ------ Phone--- r Installation will serve: Residence` parfinent House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living units: ._ Number of bedrooms _-'- Number of baths __/__ Lot size Wafer-Supply: Public'system" Community system ❑ .Private ❑ Depth to Water Table. Qft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loa `f]" Clay Loam❑''Clay ❑ Adobe, ' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic.fank or cesspool permitted if public sewer is available within 200 feet.) ptic Tan D;stance from nearest wefl-----------------Distance from foundation________________ell ___Material____________._____-___________ ----•- ------ No. of compartments ----Size-------------------- - Liquid,depth---------- =Capacity -, Disposal Fie Distance from nearest well________________Distance from foundation__ ___-Distance to nearest lot line________________. .❑ Number of lines----------------�y---------v=---Length of each line----_-------------------•-----Width of french.------------------------------- Type of filter maferial--------------------------Depth of'filfer material----------------------- length---------------------------------- Seepa e f: Distance to nearest well�r Distance f m fo anon_. _-------- Distance; to nearest lot line______ _ __--_ Number of pits--_._�-------------Linin material l Lining }�----.- - __..Size: biameter___-___ ' ' � - ��----- Depth-- ---------------- El Size: Distance from nearest weft_______________ _Distance from foundation____________-- --- .Lining material------------------------------------- r ❑ Size: Diameter ---------------------- ---------Depth---------------------------------------------------Liquid Capacity-- ------------ gats. Privy:, Distance from nearest well ____---------______________ �} -_____-_____-_--_Distance from nearest building ---•---------- ❑ � Distance to nearest lot line _ Remode' an or repairing (describe):__� _�� -------------- -------------- Remodei Remode' -----------------•-------------------------•----------.--------------•-------------------------------------------•----•-------------------------------- --------------- ----------------------•---------------------•----------------------•-------•--•-------------+-=- -----•---------------------------•--------------------•--•---------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws; and le nd regulations of the San Joaquin Local Health District. ]Signed)-----•----- ---- •-- ---- {------ -----------(Ow By= --- _ Contractor] `ne-r and/or [Plot plan, showing size o ot, iocafion of system in relation to wells, buildings, etc., can be I ed on re " g v se side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____________________ _ REVIEWED BYDATE-- - - - - - ------�-----------•-------- ----------------------------------------------------------- ------- -- - --------------------- , Y DATE--- r BUILDING PERMIT ISSUED--------------- # --------------------- --------- -------------------- -- -= DATE Alterations and/or recommendafions:---- ------,_:_ --- . •= . -------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- -------------------------------- -------_-_-•--------•-------- - -- FINAL INSPECTION BY----- --------- �{ ------------------------- Date_- . - --- ----------------�--------- -�'-- SAN JOAQUIN LOCAL.HEALTHDISTRICT 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