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APPLICATION FOR SANITATION PERMIT Permit No. (Complefe in Duplicate) L� Date Issued ppto°the San Joaquin Local Health District for a permit to construct and install f6 work herein described. This application is made in compliance with County Ordinance No. 549. licatian is hereby made Jt JOB ADDRESS AND LOC ION..-____ r f - - Owners Name------------------------ - ------ -- ------- ----------------------------------------- Phone --------- Address--------- ( F - - - ------------------------ ------------------- -•------------------------------------ Contractor's Name---------------- -------• ---------------------- Phone --------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/`___- Number of bedrooms _ Number of baths -------- Lot size _ -- _-_-_____------ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table --- --- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe Hardpan Ej Previous Application Made: Yes ❑ Noew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep tic Tank: Not of com Noance. of well�a___-Distance from foundation/�-------.Mate�iai__-� __ , p nts Size / Liquid depfh - ------------Capacity Disposal>1d Distance from nearest welL� 0-----.Distance from foundation-_ f f_____________Distance to nearest lot lie_--��_^___� Number of lines---- ------ --- - --Length of each line-------, Q -----� Width of tren Type of filter material_ -- •- r--Depth of filter ma#erial__��--____---Total length___--- . --_�------------------------ See a e : Distance to nearest Il-��_______-__Distance fro {oun ation__Z'ZZ __.Di tame to nearest lot line__-��__.--.-.� p g Number of its----- _. Linin material-__� p g -Size: Diameter-- Depths?'� Cesspool: Distance from nearest well---------------._Distance from foundation----------. .------Lining material-___________________ Size: Diameter Depth --------------- ------------------------Liquid Capacity---------------------------.gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin ❑ Distance to nearest lot line ---------- 017 Remodeling and/or repairing (describe)------------ -- _ ------------ ----------------------------------------------------------- ---------------------•--•---------------•--------------------•---•-----•-----------•---•--------- -----------------------------------------------------------------------------------------------------------------•----- -------------------------------------------------------•----••-----.-----------.---------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r lafions of the San J quin Local Health istricf. (Signed)--------------- ( ,i` -�/aF/ Own r n ( d/o ontractor) ---------------- Plot plan, showing size of lot, location of•sys+em in relation to wells, buildings, etc., can beplacedon revers __ __ { P g _-_ a side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- - -- ---- ---- DATE--- -_/�„�- '--------- ------ REVIEWED BY---•-____-- ------------------------------------------- - ----------------------��------- ------------------- ---------------------------------------------------------- DATE------ --------------------------- BUILDING PERMIT ISSUED---------------------=----------------------------------------- --------------- DATE . Aterafions and/or recommendations:-__.__----__-------------_---_--__ -------------------- I ----------------------------------------------------------------- ------------ -- - ---------------- - // 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 8-51 Revised W-2100