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i PLICATION FOR SANITATION PERMIT Permit No- ------------------------ (Complete ____.-__-___..._-----(Complete in Duplicate) C.-�� Date Issued ______________________ � /a - Applica=ion is hereby made to the 5 y�oagyyNr��i t District for a permit to construct and install the work herein described. This application is made in co 'a( e"�urithLC�ounty Ordinance No. 549. - JOB ADDRESS AND LOCAT ON__ _ - - i ---------- - ----------- ---------------- -------------------------------------------------------------- Owner's Name = --------------- ----------------------------------------- ------------- ..... . Phone.----------------------------------- .. v , Contractors Name...... -- -t — ' Phone f ` Installation will serve: Residence Q' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other Number of living units: Number of bedrooms ---.. Number of baths Lot size Water Supply: Public system ❑ Community system ❑ Private [r' Depth to Water Table ft: Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [+Hardpan Previous Application Made: Yes ❑ No Q New Construction: Yes d No ❑ �\ TYPE OF INSTALLATION AND SPECIFICATIONS: _R� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest veli - ...:. _Distance from fourdat)on_-._-._ Mater- I,.----------------------- - -f No. ,�,f compartments---- '- -- Sizer----•-- -------------------Liquid depth..... '--. ---------Capacity _-..-__---_-' - -_-'-.Distance to nearest lot Disposal Field: Distance from nearest wellm.Distance frofoundation _- Number or lines--------------------'.------_--..._Length of each line-__----_----,-.---.,__.--.Width o€ trench.__- ,'.f._-- Type of filter material ----------------------Depth of filter material-.---- -- --------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..-------------------------- - Cesspool: Distance from nearest well-------------____Distance from foundation ----------------- Lining material------------------------ ❑ Size: Diameter..................... - - -..-----Depth-- ---- --- ----------------- - - - -- -.- ------Liquid Capacity_.------------------------gals. Privy: Distance from nearest well------- ---_--- .._------Distance from nearest building---_.______________________ ❑ Distance to nearest lot line------------------------------------------------------ Remodeling and/or repairing (describe)---------- ----- ----- ----------- ----------------------------------------------------------- ------------- ----------- -----------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------- ------------ ----------------------- --------------------------------------- ---••---------------------------------------------------------------- --------------------•---------------------------------------- I 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 Joaquin Local Health District. {Signed . 9 ) --••-------------- - {Owner and/or Contractor) By: -- ---- ----------------------------------------------------------- -(Title)---------- --- - ----- ----------------- - -------------- --- y f y ---'-- (Plot plan, showing size of lot, location of system ih relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------- - - DATE= -------------------------------------------------------- REVIEWED BY------ ------------------------ -------- ---------- ------- -------------------------- . DATE.-"" -- ------------------------------------------- BUILDING PERMIT ISSUED-------------- --- --------------------------------------------- ---- ------------------------------- Alterations and/or recommendations:-_--------------------- ---- - FINAL INSPECTION BY: Date.f.� ! ..;.- -7- ; 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—`7 145age AIWOOO