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APPLICATION FOR SANITATION .PERMIT Permit No. --------------------- omp �r { � � (Clete in Duplicate)� bate Issued - °�' -� Appl cation is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h ' described. This application is made in compliance with County Ordinance N . 544. ---------------- ------------ ------ --------------------------------------------- JOB ADDRESS AND 1,9 ATIO Owner's Name----------J►/=' -'• -• ----------- Phone----------------------------------- -------------- ------------------------ Address---------------------`�� ------------------- - -------= --•-----------------••---------------------•-------------------•-•----------------------------------- ------------ Contractor's `4 ------------•----------=-----------------------•----------------------------- Phone.. .d f Contractor's Name-------------- -,----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel. ❑ Other [I Number of living units: __I__ Number of bedrooms ---L_ Number of baths ../..• Lot size _. ' '/roa/ Water Supply: Public system ❑ Community system ❑ Private �pth to Water Table _ld ft. Character of soil to a depth of.3 feet: 3 Sand E] Gravel E] Sandy Loam E]. Clay Lo m El Clay E] Adobe Hardpan ❑ Previous Application Made-'. Yes ❑ No New Construction: Yes No f TYPE OF INSTALLATION AND SPECIFICATIONS: A (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation------------- ------Material--------------------------------------------------- [� ❑ No. of compartments--------------------------Size------------------- ------------Liquid depth---------------------------Capacity----- Disposal Field: Distance from nearest we I_. -__..-Distance from founds"tiuon----Y,_._f .__.__.Distance to nearest lot Eine..... ......... °io► Number oz lines-------------- ._it_ Length of each line------/--Q,-_____ Width of trench__._sP-_Y_�._______.____ Type of filter material1A____��`"� Depth of filter materia l_-____-J. �r_--.Total length--_------- t.'--------------------- Seepage Pit: Distance to nearest well- -----------------Distance from foundation--------------------Distance to nearest lot line--__-._...-.__._- ❑ Number of pits---------------------Lining material-----------------------Size: Diameter---------------------- Depth---------- ---------------------- Cesspo,e�: Distance from.nearest well-----------------Distance from foundation._.-----------------Lining materia--._----_.--_-_--_._-____.-.--.-.--__ ['J Size: Diameter------- -------------------------- - De---------------------------- p = ------------ ------------------- ----------Liquid Capacity---_-----------------------ga4s. Priv Distance from, l- _ ,nearest wel --_ _._.--____.De__t ____________________Distance from nearest build•ing.----------------------------- ----------. ❑ Distance to nearest lot line-----------------------------------------------------------------------I-------------------------------------------------------------------- ------- --------------- ---------------------------------I-------------------------------------------------------------------- - k ry Remodeling and/or repairing (describe)=----------------------------------------------------------------------------------------------------------------------------------•---------------------- - x ---------•------------------- ---------------------------------------------------------------------- -----------•----------------------- -•----------------------------•------------- -------------------------- -------------------------------------------------------•------------•------------------------------ + F ------------------•------------------•------------------------------••-------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta ws, and rules and regulations of the San Joaquin Local. Health District. � t �("-'�1� (Signed) •----- --- ----------------- - Contractor) rand/or • ------------(Title)-- By•----------- - (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-------------- — rS REVIEWED BY-:------------------------------ --------- - - ------------------------•-------------•---------------------------------------- DATE--------------------- ---------------------=---------------- - - BUILDINGPERMIT,ISSUED---------------------------------------------------------------------------------------_----------- DATE--------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------- --------------------=------------------• -------------------•---•--------------------------------------------- 1 ----------•------•--• ---------------• ------------ ------------------------------------------------ ------------ .: ------------------------------------------------------------------------------------------------------------- -----------------• ------------------------------------------•------------------- -------------------- ------------------------------------ i -.5.------ - TION. BY:--------- -------=-------------------- Date------------- � FINAL ENSPSAN 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-4-2M 10-52 Revised W-2100