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APPLICATION FOR SANITATION PERMIT Permit No. ..� (Complete in Duplicate) Date Issue -- --------------- Application is hereby made to the San Joa u'n Local Health D' trict for a permit to construct am iristalkthe-workherein described. This application is made in compliance wit ty Ordina o. 549. JOS ADDRESS AND L ATION •• ------ ----�- ---- ----- - ----------- JOB t f - --- 4 Owner's Name-------- ------ Phone ------- ---- ---------- Address-------------: �7[1 r � L3—o-S ------------------ - ---------------- ---------- ----------------.r-z- 1� Contractor's Name .+- ----------------------- Phone-- Installation will serve: Residence Dj� flpartment House ❑ Commercial ❑ Trailer Court ❑ Mot 1 ❑ Other ❑ Number of living units: --/___ Number of bedrooms - Number of baths ---/__ Lot size __--- Water Supply: Public system ❑ Community system ❑ Privateg Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam;KC€a ILQam [] Clay ❑ Adobe ❑ Hardpan ❑ N Previous Application Made: Yes ❑ No 54�_ New Construction: Yes ❑ No `J TYPE OF INSTALLATION AND SPECIFICATIONS: _ _(No septic tank or cesspool-pe�mifted if public 2wer is available within 200 feet.) � Se ti Tank: Distance from nearest well-----�J-----T Distance rom foundation---- s `-'�- p 7 -- - � �-�---Material__.--------- ------------------ - ---•: No. of compartments -----------Size_ � _Liquid dept-a ,�-._____ Capacity-�3 Disposal Field: Distance from nearest well.�7_. -- __D f3nCe from fGfo nZ ta�iQ ___�f. -t.Distance to nearest lot line---/---_-__ Number of lines---------�.---_----- Length of each line__`KQ'f_ _ Width of trench-._PR__j_e!!__----_-.-_I Type of filtermatenaL._ j - epth of filter material---__ _-_._-__Total length- .Seepage Pit: Distance to nearest well----------------------- istance from foundation---..-----_--_-_---.Distance to nearest lot line-_-----.----_-- - ❑ Number of pits----------------------Lining material--------------------!Size: Diameter-----------------------Dept h----------.--------------------- Cesspool: Distance from nearesf'well_--_---- --Distance from foundation------------------- Ching rxaterial--------------------_--------_-__---_ ❑ Size: Diameter------------------ --------------------Dept h------------------------------ -------------------Liquid CpacitY gals Privy: Distance from nearest well_----------------------------------.-.---------Distance from nearest building-----. -_-----.----__------_----___. Distance to nearest lot line Remodeling and/or repairing (describe)-------------------- ---------------------------------------------------- --------------------------------------------- ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------•--------------------------------------------------- ------------------------------- ---------------------------------------- I hereby certify A I ha a preparedjfyhh',S!0plication and t t the work will be done in accordance with San Joaquin County ordinances, State laws, n es ano regof the S n J quip Local Health District. or Contractor) (Signed) . -------- . ----------- By:------- -------------------•--------------------;---•------_-;------r-------- - ---- --- .. - - ---•-• - -:--` ---------(Title) --- _ -- �_4 (Plot plan, showing size of lot, location of system in relafio a wells, buildings, a c. can be laced on reverse side). FOR DE ARTMI_NT USE ONLY APPLICATION ACCEPTED BY--- DATE ----------------- EVIEWED BY — - -------- ------ :-- -------------- ------------------ DATE- BUILDING PERMIT ISSUED----------------------------------- --------------------------------•----------------------- DAT-5----------- ` _ Alterations and/or recommendations:--------------------------------- --------------- --------------�oS` - ---------------------------------------------------------------------------------------------------------------- ------•--------- ----------- ------------------------------------------------------------------------------------------- ---------------- -------------------------------------------------------- -------- FINAL INSPE TION BY: ---- ------ Date-------- ,�.�-. �.j �/ / � -- - M_ 1 b SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American freet 300 West Oak Street 132 Sycamore Street ' 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M I0S2 Revised W-2100 1