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i� .�` APPLICATION FOR SANITATION PERMIT Permit No�- (Complete in Duplicate) Date Issued!--o _I( Applica+ion 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 County4rdinance No. 549. Fes. r� � - JOB ADDRESS-AND LOCAT ON _ ; _ �� ,f Owners Name / , ----- Phone A --- Address -� r �� ----------- -------------------------------- -------------- Contractor's Name--- - ------- •-------------=' Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Molel ❑ Other ❑ ----------------- Number of living units: -.-�--- umber of bedrooms -2I- Number of baths __4---- 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 ❑ �I Previous,Application Made- Yes ❑ No New Construction: Yes M No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: within 200 feet 44 'r (No septic tank or cesspool ermitted if ublic seer 1s available P P , D��Si ntie from fours tion-� Mat ri i_ ........ Septi ank: Distance from nearest wellha�-�...--- 11 ��tt No. of compartments--_____.-- - __Liquid Oepth�-----:- -----------------Capacity-----_!_- -f0_-- F ------- - --- -.. ce from foundation! _--- istance to nearest lot line_�f �" ��'1� 05 Dispos Field: Distance from nearest well0-_- -- Number of lines--------------_e y- Len th of each line----___ _- Width of trench------- --.-__�-__.-.___-._-- Type or filter materr - - T '`�-Depth of filter material--------- ---- - ----Total length--__----.- --- t_ ---__ : ------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------- El Number of pits----------------------Lining material:''.--------------------Size: Diameter-----------------------Depth Cesspool: _. Distance from nearest well-----------------Distance from foundation___.--- .----._ Lining material--------------------------------------- V\ ❑ — - -__ iduid• opacity -- - Sls ze: D+ameter Derma{h = I .� ., .. t`. ,..xsr5,r-' wr..'Q-W.*M..+ekee— s—.`.o.a� Privy: Distance from nearest well-------------------------------------------------Distance from nearesr building------------------------------------------ �j ❑ Distance to nearest lot line---------------------- -------------------------------------------------------------------- of{ Ib 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 laws, and rules and regulations of the San Joaquin Local Health District. ` Owner and/or Contractor) 1 By:------------------------------------------------------------------------------------------------------------------------- -----(Title)---------------------------------------------------------------- jPlot plan, showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on reverse side). FOR DEPARTMENT USE ONLY 4 APPLICATION ACCEPTED BY- — DATE----------- -------------------------- ----------- .REVIEWED BY---------------------------------- -- ""_ DATE- ; BUILDING PERMIT ISSUED-------------✓ ---- ----- ---- ----•---------------------------------- DATEj Alterations and/or recommendations:--------- r--------- --------------------------------------------- - - --- -. ----------------------------------------- f ----- ---- /_-- FINAL INSPECTION BY: -- -- ----_ --------- - ---------- Date----// ---- -----�------------------------------ 1 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 Revised W-2100 -�_: