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APPLICATION FOR SANITATION PERMIT Permit No. ._____ --••--:---- (Complete in Duplicate) t Date Issued Application is hereby made to the 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� JOB ADDRESS AND LOCATION._.-_ a--1---- •k-- "-" "- ---------- � "---------------------- ------------------------------------------------ Owner's Name------- ------------ --------------- ----- ---------- Phon0p ---------------•-•-----....-------------•------......----------------•---•------------------------------------...--------- Contractor's Name------- v-_-----•---- 4 -----'�--' -- --"-------••------------------•--- Phone---/-----!__---Q.f------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r t Number of living units: __1___ Number of bedrooms _A_ Number of baths ___L Lot size __`1r��.____. . .---------------•-------- Water Supply: Public system [P�Communify system ❑ Private ❑ Depth to Water Table __Mft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe[Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes UT"'No ❑ TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest well______.__ Distancyfrom foundation____ Q__..__.Materi�rl__C1_ __ -----.---.- ---- __Liquid depth----_ � No. of compartments---- ---�------ Size- l��_ X :Capauty Q Dispos Field: Distance from nearest rwell__ __ _.Distanceefrom oundation____- �1_e______-Distance to nearest lot Ione_____ _�___ O Number of line ------.�- Length of each line-------1®----------------Width of trench----;a�1 ---------------- - Type of filter material��.______�._ -----Depth of filter material-----f. _._ . ----Total length---------�Q---------------------------- � 1 See pa Pit: Distance to nearest welL,._._ r'1.______Distance e f om fou dafion----r _ ___.Distance to nearest lot line__..____._ [ Number of its._____- Linin material -0_ -Size: Diameter__._.�. _�'___.Depth____ -- �_________________ p g Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________________________ ❑ Size: Diameter---------------------------------------Depth-.--------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building..________.__.________________.____._..._. i ❑ Distance to nearest lot line------------------- ----------------- ------------------------------ -----------------------------------=---------------------------------- Remodeling and/or repairing (describe):----------"--------------------------------------•"--------•--•------------------------------------------------------------•-------------------------"-- I ..... -----•-----------------------------------------------------•---------------------------------------------------------------- s, __________________ _______________ _________________________________________________________________________ _ _________________________________________________».-_____..-___________________-_____________.__._ ________________________________________________________________________________________ I 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 regulations of the San Joaquin Local Health District. (Signed.. ------------- --------------------•----------------------------- ------ r and/or Contractor] • - ----- - a Br• rile �------------------------- --------------------------- ------------------------- ( ) (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 ¢f REVIEWED BY -------------- ----------------- DATE' BUILDINGPERMIT ISSUED----------------------------------- ------------------------------------------ ----------------------- DATE.--------------•-------------------------------------------- i Alterations and/or recommendations-------------:------------- ----------------•-------------------------------------•------------------••---------•-------------------- -•-•---------------------------I-------------------- -------------•--------------------------------------------------------•-------------------------------------------------- ---------------------------- --•----------------------------------------------------------------------- FINAL INSPECTION BY:----. `� ' Z�j/-rj #"- Date---------�--------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100