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APPL)CATION FOR SANITATION PERMIT Permit No. om lete in Duplicate) ., {Cli �p PDate Issued _111-44y w • w 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 County Ordinance No: 549-.- J = ----- -----•--•-------_------------- --------- JOB ADDRESS AND LOCATION____.-�_ ------� ---------------•----�f-- - -- Owner's Name,, ..'..1-------------------------------------------------------------- Phone ---..----- �J. /-- , Address----- ------------ '' " -------- ----------- ------------------------------ -------------------------------------- ---------------....... Contractor's Name-------------- .y = ---- ---------_.------ ----------------•----------f-----_-- -- Phone �a6 Installation will serve: Residence ElApartment House El Commercial ❑ 'Trailer Court] Motel ❑ Other ❑ Number of living units: --- Number of bedrooms __/__�.Number of baths --_--- Lot size ---_ _��__- ._ �---•--------------- Water Supply: Public system ❑ Community system ❑ Private E5-15epth to Water Table 3-rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Andy Loam ❑, 661y Loam ❑ Clay ❑ Adobe R—Hardpan ❑ Previous Application Made: Yes El No D�New Construction• Yes e o�❑ TYPE 'OF INSTALLATION AND SPECIFICATIONS- l (No septic tank or cesspool permitted if.public'sewer is available'within 200 feet.) ' �/ ' ------- Septic�T nk: . Distance from nearest well---`5d--____Distance from foundation__ -_-_--. ..Material_.�-C-J.c_______-_---_-_-- No. of compartments_..___.�-------------Size_.S6_ ` ----------Liquiiid/�depth-----—-------Capacity__..$ --d------- Dispos-S�Field: Distance from nearest weK__�_Q-l_._Distance,from,fcundation__�._e-r-----Distance to nearest lot line----S�-_-- EB" 7 la +. L`� _ Number of�lines_*_____.l_'----------------------Length of each line---------------------;------.Width of trench--_-_-�- ---------------__-•-- / i �d i Type of filter material.�_%�a�%___Depth of filter material,/ length length.-_-___al___�___________________________ -.-Distance from foundation--------------- .Distance to nearest lot line______-_-------_ f+' Seepage Pit: Distance to nearest well---------------------- , ❑ Number of pits------------ ------Lining material----------------------.Size. Diameter-----------------------.Depth--------_-,---------------------- X Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------.Lining . --------------------------------------------------_ material_-__-._-__----.---_-----.-----_---_-_-_-----_-;_,-.--9----.-- as,Size: Diameter----- - --- ------------ ----------Dp ; L�qui apacitY- ----- Privy: ------------------ Distance from nearest well-------------------__-.----_-_---_..__-_---._..-Distance from nearest building----_---_-_-- --__-__--_--_____-_-_--._- ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------- --•---------------------- Remodelingand/or repairing (describe):---------------------------------------------------------------- ------------------------------••-----------•--------------------------------- ---•--- ----------•-----------------••--------------------------------••------------•------------------•-----------•------------ ------------------•--•----------------------------- - --------------------------------------------------------------------------------------------------------------•-=--------------------------------------------------------------------.------------------------- . ' ! hereby certify that 1 have prepared this application ariT'-+kat the o k will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Sign ) > '"" _ ------------------------------ ed { Contractor) , By-------------- ----- ------------------------ ` -'-- --------------(Titl (Plot plan, showing sizeiof lot, location of system in relation to wells, buildings, etc:, can be placed on reverse side). I � FOR DEPARTMENT USE ONLY IAPPLICATION ACCEPTED BY------ ---------------- -------------------------------------------------------- DATE------------- -------------------`------- ----------- REVIEWEDBY----------------------------------------- - - ------------------------------------------------------------- DATE --------------••---- --------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------= Alterationsand/or recommendations:------------------------- ----------------------------------------•---------.-----------------•-=-=-------------- _.........._..---------------------------- -- -- --------------------- -- ------------------------ ------------------------------------.... 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-9-211 Revised W_2100