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.. APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate). ? Date Issued pplidation is hereby made to the San Joaquin Local Health Distr cf-for a permit to construct and install the work herein described. is application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION____ -------- ----- --------- ---- ------ -- - -•-- - --- Owner's Name- --------- ------- . -----•- --------•-- -- ----- --------- -------- ------ --- hone Address-----------•-A-- - -- ---- Contractor's Name.. - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms .- . Number of baths -_ Lot size '__ -,�-k-Q----_ -- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table f-$ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ , Previous Application Made: Yes ❑ No kNew Construction: Yes ❑ No [ / TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 fee+. Septic TJarik: Distance from nearest well_._ Distance from foundation___ ---------Material___--- ----------- No. of compartments_.::".�_---------Size.S' 4K3�_) -_4 __Liquid depth_____ �______- --_Ca acit 1 P Y---7--4-p._ Disposal Field: DistancE from nearest-well_.-_-_-----------Distance from foundation--------------------Distance to nearest lot line_______________. , ❑ Number o-i lines---------- ----------------"--Length of each line------------------------_----.Width of trench.------------- ----:-- Type of filter material-----------•-------------Depth of filter material----------------------Total length ------------------------------------------ �. Seepage Pit: Distance-to nearest:wel------------------------ Distance from foundation-------------------- - ____.Distance to.nearest lot line---------------- Number of Pits-------------!�--t-----Lining material----------------------_Size: Diameter----------- ------Depth--.------ ----------------------- Cesspool: -------------- -- Cesspool: D}sfance from neares#,weil__'---------------Distance from foundation--------------------Lining material____-___--__-____________-.____.-___. t. ❑ Size: Diameter------- ° ==" P"` Depth------ ----•------------ ---------------------Liquid Capacity----------------------------gals. Priv Distance from nearesf, well -'----- Distance from nearesr building__-_.____________________ Distance to nearest lot line___' _--.__________________________ Rem Jelin nd/or epair' g (describe :_ _ - --------------------------------------------- ------- ------------- - ------- -------- yZo r:------ - ---•----- --- -- -- ---'----� ---•--` t`"� --------- -•--------------------------------------- -- .------------------- - ------ ............ ----- --- --------------------=--------- •---------------------• _ --------- ---------- ------ -- - I hereby certify that I have prepared this application.and that the work will be done in accordance with San Joaquin County- ordinances, State I and rules and regulations of the San Joaquin Local Health District. (Signed).,)---- -- -- -------------------- --- ----------------------------------------------- ---------------- -------low --- -- ----- ---- - ----•------- Contractor) ___ w nd/or C or� ---------(Title)----- ----------- ----- - l - - - ------------------------ P of plan, showing size of lot, location of system jn relation to wells, buildings, etc., can be placed on reverse side). ` f FOR DEPARTMENT USE-ONLY APPLICATION ACCEPTED BY----- --------- DATE REVIEWED BY t DATE- ��j } BUILDING PERMIT ISSUED ' r DATE . --- ----- Alterations and/or.recommendafions:----------------------- ------------------------------------------•-•---- ------------- ----------------- •---------------•-------------- ----------------------------• ----------------------- --- -- :------------------ ------- µ ------------- FINAL INSPECTION- BY: = .- _= 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 L Manteca, California Tracy, California E5-9-2M to-52 Revised W-2100