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Permit No. ._�-T`- APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued .!------ ---------- - Application is hereby mad to the San Joaquin Local Health District for a p mit to�co�nstruct an i tdescribed. all the work herein This application is made,in gompliance with County Ordinance No. 549. _` JOB ADDRESS r ATION TION--- JOB - 1 ------- Phone----------------------------------- --------------------------- Owner's -------------------- Owner s Name--- ------'-- -- __ ._..�- ------- = ---------------------------------- --------- --------------------- Contractor's --------- ---------•---- Con#ractor's Name �I - --•-- •- Phone -- - - --- --- 4. 'A tment House ❑ - Commercial Trail7r Court ❑ Motel ❑ Other Installation will serve:. Residence ❑ p Number of living units: Number of bedrooms _b.-_ Number ----- Lot size ----------------- Water Supply: Public system-F1 Community system El Private �DeptbWater Table -------- ft. � Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan E] Previous Application Made: Yes ❑ No K New Construction: Yes x No ❑ TYPE OF INSTALLATIONkND SPECIFICATIONS: is • rt...' •� _ - [No septic tank or cesspool permitted if public sewer available w�thin.200 feet.]—_s ._ -- Septi Tank: DistanFe from nearest well-.�7rd--__Distant from founds ' n---.- __ Materi I_._ ._-- ------- ------ No. of, compartments---------- -----Size___-__-_-:- LiGuid depth----- -- CapautY a -� Disposal Field: Distance from nearest well___�_Q_-Distance from foundation-._-��--.Distance to nearest lot lin l_ Len th,.of each line-----___- _ _--.Width of tri. ... of lines--------1 eP 1 Type f filter"material---_.�� h of filter material_------- -- Total length.-_----r�l�------------------- - Seepage Pit: Dista�I�,Ce to nearest well=---------------------Distance from foundation--------------------Distance to nearest lot line_--.�_----__..- ❑ Num Lir of pits------ ---------------Lining material-----------------------Size: Diameter---------- Deptn-._. �fI -------------------------- - � Cesspool: Dista�lce from nearest well ____--_Distance from foundation--------------------Lining material----_ _ _ ❑ .. Size:.l7jameter -----Depth !gid Capaci_ -------:�: Privy: Distance,from nearest well------------------______-..____--_-.-___--_----Distance from nearest building - I ❑ _ � Distance to nearest lot line ----------- ---------- -------------------------------------------I-- .� �-�!.- .-- -- te-�--rb� -�-- '-�� Remodelin and/or epairing (describe):-----_'" - -- ------ -. Ytld ------------ -----------------------------------------��-- -----------•------•------------------------------------------•---------=--------••-----•----•---------- ----------------;-----------------------------------------------. . ! hereby certif +hate I have prepared this application and that the work will be done in accordance.with San Joaquin County ordinances, State laws, a"nd rules and regulations of the San Joaquin Local Health District. ----------------------------------------[Owner and/or Contrac og�-• 1, [Signed]----- - - -- ---- �� =-----------(Title)-----------•------------------ --------------- -------------- By:--------------•----------I-•---- - - -- - ' [Plot plan, showing size of lot, location of system in relation to wells,• buildings, etc.; can be placed on reverse side). - � �M FOR DEPARTMENT USE ONLY APPLICATION ACCEP�fED BY -------------- ------------- ----------- DATE-------------- ----- REVIEWED BY------•- -------------- --------- - DATE---------------+-- ------.-------------- BUILDING PERMIT ISS QED ------------ --------------- DATE. - Alterations and/or recommendations: = --------------------- - ---------• --------------------------- -----•----------------------------- �� ---------------------------------------------------- ------------------------•---------- ----------------------------------------•-•--------------.-------•----=------ If ----------------------------------------- ---------------- ----------------- I.......... ------------------------ ---------------------------- • ------:---------------- . FINAL INSPECTION BY:.------- Date------ 4� SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 13o South American SIIIt�rest Trac California Stockton, Californip Lodi, California P. Manteca, California Y iII 4 ES-9-2M 10-52 Revised iw-2100