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O APPLICATION FOR SANITATION PERMIT Permit No,..J'..__3_., (Complete in Duplicate) Date issued ca#ion 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 w'th County Or ' ante No. 549, JOB ADDRESS ANP LOCATI N----- ----------- __ _ � ++ r: t Owner's NamQA,-- --- •¢ �? r -�" j' f ------------------------ ----- Phone---- Addressf r _2----------------------•- --------- •- ----- -------------------------------------•----------------------------------------------------------- Contractor's --------------- - - Contractor's Name... --------------------- Phone------------------- Installation will serve: Residence Apartment H se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: ---- Number of bedrooms Number of baths.__ ---- Lofi size X-1 Wafer ^F -Water Supply; Public system ❑`Community system ❑ Private Depth to Water Table -___ ft_ Character of soil to a depth of 3 feet:. Sand ❑ Gravel:❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No � New Construction: Yes 0No��] I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200.feet.) Septic Ta Distance from nearest well-----------------Distance from foundation-------_-----------_Material ____________.______________________.__--____--. No, of compartmonts. Size ------- --------Liquid depth----------------------- Capacity Disposal Field: Distance from nearest well_-- 5 -_Distance from foundation_____ _ . r � _ .Distance to nearest lot lin ___� --,, Number of lines---------- ------------------- Length of each line---- . ----------.Width of trench---_- Type of filter material__ _Depth of filfer material___ --- p Total length --------------- 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----------------- --------------•- _ �.._�...- _ _ w. ,-� g ,n ---------- --- ------- �..... � _- - ___— ti _� iquiv_Capacifiy_:-�T::.�-_-:.:- _gals-�. , Privy: Distance from nearest well---------------------------------------------------Distance from nearest buildin g ❑ Distance to nearest [of line------ --------------------------------- ------------------------�------- ---t•---------------•f------------------- ------------ �- Remodeling and/or repairing (d scr' e _ ,-- _. .__ # __ -----------------•--------------•-------------- ------------- --------------------------- ----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ - 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)_ � _.-,_,_. - ( �,( �y�-ten----- y --- Owner and/or Contractor) - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can placed on reverse side). s FOR DEPARTMENT USE ONLY .APPLICATION_ACCEPTED.BY----- ---------------------- ----- __ --- ----- -- DATE 't <--_ _ . REVIEWED - T._ F BY -- - -------------------------------- --------- a DATE . - - ' y BUILDING PERMIT ISSUED------------------------------------------- __VN!-•�---------------------------------------------------------------------DATE---------------- ----•----------------------------------- Alterations and/or recommendations:-------------------------- ------- ------------•--------------------------------------- ---------------•-------•-_--------•------------------- --------•--------------------•----------- •-------- ---------------I-----------•------•---------------------------------------------------- f FINAL INSPECTION BY____________________ _ y ej '-2— S��¢- ------- Date---- ------------ - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street f32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9---2M 10-52 Revised W-2100