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APPLICATION FOR SANITATION PERMIT Termif No. l [Complete in Duplicate] Date issued /-!?Y Application is her by made to the San Joaquin Local Health District for a permit/contruct and insfall +he work herein described. Thiapplication is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDCATION - ----------------------------------------------------------------------- x Owner's Name--------�zt= ' _ ---- --- - -------------------------------------------------------- Phone------------------------------------ Address---------------------------- ---- ---- - ---- --=--= n __ - ---- -- -- Phone Contractor's Name________ _ __11__ �___`�'_ � - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/ ber of bedrooms__ Number of baths _�___ Lot siie ----� �:__� �_ °�/----________ Wafer Supply: Public system Community system ❑ Private'❑ _Depth to Water Table_ ft. Character of soil to a depth of 3 feet: Sand avel ❑ Sandy Loam lay Loam ❑ ' Clay ❑ Adobeardpan ❑ � 6 Previous Application Made: Yes E]I No New Construction:'Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sep+ic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic n Distance from nearest well----------------:_Distance from foundation--------------------Material------------------------------------___------------- ji a. of compartments ___Liquid depth Capacity-_-' ip --------Size----------------------------- q P ,---------=-------- Disposal F' Distance from nearest well------------------Distance from foundation__________________.Distance to nearest lot line----------------- y Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------ ------------ Type of filter material--------------- Depth of filter material-----------------------Total length--------------------------_--------------- Seepage Pi Distance to nearest well ________Distance fromEfo '`dation � ________..D1 toynce to nearest tline----- at 0 Number of pits__ +iEtS+ ___:___Lining material_-__Size: Diameter___ Depth__ ° __________________ Cesspool: Distance from nearest well_________________Distance from foundation__.---------------Lining material________ ____._,_------------------------ ❑ Size. Diameter---------- ---------------------------Depth-------------------------- -------------------------Liquid Capacity----------------------------9als, Privy: Distance from nearest well __Distance from nearest building__ _ _________ ----------------------- T-1 __-_- _ -_ --- Distance to nearest lot line_ ___ -------------- ;P+ ❑ -- - ----- r Remodeling and/or repairing [describe):---:----- --- ------- ------- ------ " ----------------- -------------------------------------------------------------------•- ------------------------------- ------------------------------------------- --------••-- ---------------------------------------------------------------------------------------- ------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la1 , and rules an- egulations of the San Joaquin Local Health District. • .. �- �] , - - --- (Signed)...----- -- ------- - - ,--- --- ---------- - -- - _ (Ow rand/ov-,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_ >_____________________________________-__--------- REVIEWED BY ------- DATE ---------------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- -------------------------------------- DATE---------4 Alterations and/or recommendations----------- -------------------------------------------------------------------- --------------- -- -------�.---------------------------------------- ------------------------------------------------------------------- ----------------------------------- --------- --=--------------------------------------------------------------- -------------------------I------------ --------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- FINAL INSPECTION BY:_ _n---------------- --------~ ----------------- Date------------------------------ .� ., SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef 3 Stockton, California Lodi, California Manteca, California Tracy, California q ES-9-2M 8-51 Revised W-2100 14