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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate)p. ) Date Issued --- Applica+ion is hereby made +o 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. JOB ADDRESS AND LOCATION____ r ---04i Owner's--Name------------- --------------- ------------ - -- ----- - ------ ---- ----- -------------------------- ----- ------.Pho e-----------------�-------------- Address--------------- -- 1 ; --------------------------- " .. 1 Contractor's Name------•--•=�---- -• -------- -,`�--�-----=-- -------- -------*- ---4--- - -- - --,�' Phone.----- --'------�------------:= Installation will serve: Residence eApartment House ❑ Commercial ❑ ' Trailer iCourt'❑ Motel ❑ Other ❑ ;Number of living units: __�---- er of bedrooms 1,-_- Number,of baths,.____ Lot size - --- __-- -.-- -- -- --------------- Water Supply:'- Public system Commun ty system ❑ Private ❑ Depth to Water Table - ft. Character of soil to a1depthof 3 feet: Sand ❑ 'Gravel ❑ Sandy Loam ❑ Loam ❑ Clay E] Adobeardpan ❑ " Previous Application Made: Yes ❑ No ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sew r is available within 200 feet.) Septic Ta3Jr� Distance from nearest well�l.�� stance from foundation_--�-Q_-____-.Mat i ---��-.____--------- --------------- [ rte of com artments--- -----.---- e--------------------------------Li uid de th--.-- ?�--------Capacity-- No. 1- - - .,, P q py ul Disposal F' d: Distance from near st well$�l-. Dis+ante from founclation__ --i-.--Distance to nearest lot line-- ------- Number of lines-- - -__. t -__ -.--- -Length of each line----- __O_-.-__i---.Width of trench----_--- - r t Type of filter materiaLS---. _- _ I Depth of filter material ��- Total length--_---_--� Q: Seepage Distance to nearest ,,,we,,A/47---. _-__Distance from f ndation_--kS._�---..D-�is7tancq to nearest lot line---,d. --__--- Number of pits.�Qs--------Lining material-e � Diamete�_,__.ld__ __-___Depth.....'-Lr�- p Distance from fo dation--------------------Lining material------_:Y----____- Cess❑{ol: Distance from nearest eiL__--� �D"epth-- ---- _- -"__-- �-Y"' " �` U(Tu Capacity_---•------_'--------------gals. I Size: Diameter------:-- -.s_�- "- -* a . .� . Privy: ' Distance from nearest-well-_-:---- --: -------------------- - = tp --- Remodeling and/or repairing.Idescribe): =`' -------- ------ ---•-- ----- ------------------------------------••----------- ------ -- ------- ---- --- -------• -- I ----- ---- ---- ------------------ --------- -- - -- ----------------------------------------------------------------- ---- I hereby certify that 1 have'prepared this application and--t--h hat the work will be done'in accordance with San Joaquin County ordinances, Stat aws, d rules a d re cations of the San Joaquin Local Health istrict. i 1 t i (Signed),._.. --"---- --- ----—-- - -`-- f W� C {Own �nd/o ontractorl 'BY: r - ------------------------ (Title (Plot plan, showing size;of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 'r { t `; 1( FOR DEPARTMENT USE ONLY A% r DATE----------- f/_/ ,.i Gj. ' APPLICATION ACCEPTED BY----.:�.- yl�I .,$C ,-• )----------------------------------- REVIEWEDBY---------------------"--1------------------- ------ ----- ------------------------------------------------------------------. DATE------------------------------------------------------------ BUILDING PERMIT ISSUED ---------------- -- DATE. - Alterationsand/or recommend ations:-----------------------------------'-----------------------•----------------------------------------------------------------------------------------------------- ----------- ------------------------------------ ----------•-•-----•-------------------------- - --------------------- ------••-•------------------•---•-•---•-----------------------------------------------•-•- --------------------------------------- ------------------ ------- ------------------------------------------------------------------------------------------------------------------------ -•---•-----•------•------- -----------------•------------------ - --------------------=------------ ---------------------------------------------------------------------------------------------------------- ----------------------------------- FINAE"-INSPECTION BY:---------- v-.'- �------•----- Date- --- --- -------- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street 132 Sycamore Street 8i4 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised W-2100 '• —-