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APPLICATION FOR SANITATION PERMIT Permit No.c�C (Complete in Duplicate) Date Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_------- -- �-- - -s--- - ` . ------------- 4t Phone---------------------------------°^-� -.- Owners Name------ ------- ---- ----- A. - , t Address----------- ----------- ------- ----- ---- ------------------- ---------- Phone Contractor's Name- i Installation will serve: Residence Apartment House ❑. Commercial '[ Trailer Court [I Mofel ❑`Other Number of living units: __ __ Number of bedrooms'_._ Num��_Depft;to.Water,Table he _/__ Lot size . --- --- Water Supply: Public system ❑ Commun.ity.system10--Private ` -------- ft. pP Y Character of soil to a depth of 3 feet: Sand ❑� Gravel ❑ Sa#ndy.Loam.El Clay .Loam El Clay F] Adobe E] Hardpan E] Previous Application Made: Yes 171No New Construction: Yes ' o El TYPE OF INSTALLATION AND SPECIFICATIONS: [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. r ❑� p �" ------' --------- Size--------------------------------Liquid depth----------------------=----Capacity----------------------- Disposal y=ield: Distance from est ell __________Distance from foundation_____---______-____-Distance to nearest lot line__-______-_-____ ❑C Number of lines-------- ---------------------Length of each line-----------------------------.Width of trench Type of filter material------------A-----------Depth of filt T }eriaL---------------------Total length----------------------------- ' r/ Dist ce,f m ound do ___ .d__. Dista ce to nearest lot line___t�.--------__ Seepage Distance..to nearest well___ __�-._.__:_ _ _ i r} Number of pits__-- -----------� Lining ma erial_ / ze: iameter�____ :----,_ __-Depth____- -r-------------- Cesspool: Distance from nearest well_______________`' ' tante from founda ' n---- Lining material------------------------------------- tance frorn ---Liquid Capacity ---------------------gals. ❑ Size: Diameter-------=--------------------- -------Dep ------------- -------- � =_ G p Y -- ----------- --------------Distance from nearest building------------------------------<----------- ---------------------------------------Privy: Distance from nearest ,well_____________�____�- ❑ Distance to nearest lot line------- ------------- Remodeling and/or repairing (describe) --------------------------- -- `---=--------------------------------------------------------- ,r ---------------------------•----------------------------- p L ____________________________________________________________________________________________ _____________________________________________ ' --------------------- ----------------- ------------------- ------------------------------------------------------------------------------------------- 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 Joaqui .Local Health Qrstrict. �. .�-_ ____-:--_ _____(Odlrner and/or Contractor) (Signed)-------- ---- - -�---- s -� 1 [Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY 1 ---- ----------- ------------ -------------- -------------- DATE _ APPLICATION ACCEPTED BY---- �-------------- ------- -�-- - -------------------------------------------- -------------- =-------------------- ----------------- 1 ---- REVIEWED BY---------------------- "-- -------------------------- -- -•- --- ------ ----------- DATE --- DATE---------� --------------- -------------------- BUILDINGPERMIT.ISSUED------ ---------------------------------------------- ----------------------- =-------------------------------------------- Alterations and/or:recommendations:--------------------------. ------- . a'�6 ____________I--___________-___. ____-_--__-_____-_____ ,t ________----------------------------- ---------------------------------------- --------------------____________f____-__ -------------- < w. ______________________________ :. _ _-__________________________________ L#V FINAL INSPECTIONBY:- ----------- r 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 E5-9-2M B-51 Revised W-2100 i-