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APPLICATION FOR SANITATION PERMIT Permit No. -.------=--- (Complete in Duplicate) Date Issued .__-.-- - ��-� Applica{ion is hereby made to fhe 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 I Ca 9 JOB ADDRESS AND LOCATION ------------- -----"---- = t --------•-------------------------------- Owner s Name ------- _ ------ ------'"---•"---" ------------------------------------------- --- -----------. Phone"4__ -��1-_ .---- Address-------�-�---3 3- --------- I... --- Phone•- .- Contractor's Name--- -------- ------------------ -{ Installation will serve: Residence P"'A"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Lot size 7 �---------------- Number of living units:---/ _- Number of bedrooms _--Number of baths _ A Water Supply: Public system"�ommunity system ❑ Private [I Depth to Water Table'7LJ ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam [I Clay ❑ Adobe ardpan ❑ �T Previous Application Made: Yes ❑ No �ew Construction: Yes &"No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) n Septic nic: Distance from nearest weVV_- bistance from foundation ---- /0-------.Material--Ci-- - No. of compartments -------az------- ----Size-1 -c'k-----Liquid depth--�J-Z-"------_"--_,Capacity------------- t Disposistance from nearest well -.-----_-._---.-Distance from foundation -_------__.-_-.---- Distance to nearest lot line ----------------- �.3' usriher of lines- ------ Length of each line --------------------- •------- Width of trench ------------------------- ------ Type of filter ---"Distance fro mi. of filter material--------------.--------Totallength -------- * ---------- Distance to nearest lot line __"_. 00 SeepPit: Distance to nearest well"-_-_".-�`-�m ounanon"__ Lf� -----_Lining material-- C. " -"- Size: Dia meter_ -_d -- Depth---"+X.5__-"__---"_-_----- Number of pjts Cesspool: Distance from nearest well-"- -------------- Distance from foundation------------- ---- Lining material_-. -------------------------------- Is. m .ger =='' ` - Li uid Ca aci----------- ---gals. ❑ Size: Diameter ------ --------------------- ---- Depth --------------------------- q P tY -------------------.-Distance from nearest building ----------------------------------------- Priv � Distance 'from nearest well______"-..__"_____________ _ -_ ------------------------- Distance'to nearest lot line---------=-------------------- - ------------------ ------ and/or re pairing ( escri a :_-__-"-=----------------- ------------------•--•-- -------------- ------------I-------------------------- •------•-- " -----•-------------------- --•"------------------------- •------ ---------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State l#WS, and rules and regulations of the San Joaquin Local Health District. I,. - {�+er and/or Contractor) (Signed) - -------------- '_. • --- -- : BY:------------- --- -------------------------------------------------------------- (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 - i APPLICATION ACCEPTED BY -------------- --------------------------------- REVIEWEDBY ------------------------------------ ----------------------------------------------------------- DATE;-. j -•--L---- Y DATE---------------- ,- __... BUILDING PERMIT ISSUED--- ------------- ----------------------------------------------------------------------------- ` DATE------------------- ----------------------------------••----- - --------------------------- ------------------------------------ Alterations and/or. recommendations: ------- -------------- - -----•--------------- -----' ------ . --------------------------- -----------.-= FINAL •ENSPECTION`BY::---- ------ -- ••------- --------------------- ------- Date. --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 914 North "C" Street 130 South American Street TracCalifornia Stockton, California Lodi, California Manteca, California y Es -9-2M ; ' Revised W-2100