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30'.to te�. ]` to-t w APPLICATION FOR SANITATION PERMIT Permit N -f.__.____ ;Z0 o (Complete in Duplicate) Date Issued ��f !01 Application 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. 7 o JOB ADDRESS AND OCA 10 ------ --- -- Owner's Name------ /� - Phon _ ---------- Address--------------------i ------ (� -0-----_- - ✓ 00 ContractorsName............-------------------------------.4 -- --------------------------- - ---------------------------------- - ------------ Phone._..----•-------------------------• lnstalla+ion will serve: Residence Apartment se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Lot size'- - _-- Number of living units: __ -- Number of bedrooms ._umber of baths __� � .�. Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table - 4�y Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes ❑ No } t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tanks istance from nearest well_________________Distance from foundation--------------------Material____.-___-___---.__-_____________.___________- jm .o. of compartments---------- --- -----------�5ize--------------------------------Liquid depth ---------Capacity Dispa a Fiehd i tante from nearest well_-. -_Distance from foundation_ r _ _- _.Dis nce to nearest lot line_________________ ber of lines--____-_1__ ________________ _Length of each line------- -J th of trench. _�D_________._._ h pe of filter material___ Depth of filter material----- e length- pe *�S ' ge Pit: Distance to nearest well_____________________Distance from foundation__1r�.. 1�__- AS-___..Distance to nearest lot iine_ S_--__ Number of pits------F/-------------Lining material-----------------------Size: aterial-----------------. .__.Size: Diameter-----------------------Depth--------------------------------- /0 ----------------------'--.-_---. esspool: Distance from nearest well_-- +�-__Distance from foundation---____� -----.Lining materia!__-_ _ ! Size: Diameter---31�--X-----1-0---------Depth --------- -------- -------- --------Liquid Capacity- `'` gals. Privy: Distance from nearest well--------------_----------------------------------Distance from nearest building-------------------_--________-.____.___. ❑ Distance to nearest lot line----------------------------------------------------------------------- --------------------- R modelin4an ar re airing (describe):--- ---- ------ -- . Z-�__ *� ( _ r- �" A_ I reby ter+ify that I have prep ed this appliE tion an that +hork will be done in accordance with San o�in t L ordinances, State laws, and rule and r gulations o he San Joaquin Local Health District. Si( g ned •r _ -t�^ (Owner and/or Contractor) By:----------------------------------------------------------------------•------------------------------------------------------------(Title)----------------------------------------------- -------- (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----- -- •----- REVIEWED BY------------------------------------------------------ �� n-� ----- DATE S } BUILDING PERMIT ISSUED----------------------------------------�rt�' ?-`-�--►------------------- DATE ------------------------------------------ Alterationsand/or recommendations:------------------------- ---------- -- - -- ----------------------------------------------------- ------------------------------•--------•------------------- - ----------------- to - ----------------- � �' --- F• --- -- - -- c -- ----------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- FIt�I 'CL�[1CI1�" ------------- ----------- 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-9-2M 10-52 Revised W-2100