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APPLICATION FOR SANITATION PERMIT Permit No. _-c _bP... .. I (Complete in Duplicate) Date Issued _____,( �S_- € 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. JOB ADDRESS AND LOCATI N--------- r -a-� - ---- ... '------------------------------------------------•----------------------- Owner's Name------------------ ---- - --•----------- - - -- ------------------------------------- Phone------------------------------------ Address # V -- --- -------- --------- :- ------------- Contractor's Name---- r _ Phone_ Installation will'serve: tResidence Apartment House-E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I___ Number of bedrooms --.? Numberaths _ _ _-- Lot size -'_____-• _- _-:_-- _ _ ----___--- Water Supply: Public system ❑ Community sy#tem„D..,�P_rivate- „Depth to Water Table�.5 ft. 3 Character of soil to a depth of 3 fee+: Sand ;Gravel'❑ Sandy Loam ❑ y Loam ❑ Clay ❑ . Adobe ardpan ❑ Previous Application Ivade: 'Yes ❑ Na ew Construction: f No ❑ TYPE OF INSTALLATION AND�S�ECIFICATIONI: Ai -, (No septic tankpor cesspool permitted if public sewer is available within 200 feet. ��--/ Septic Tan Distance _____Distance from fd ante from nearest well _ Sd undation_ (J_____.Mat No of compartmen4s_____ __ ---- -------Size___._ 'lQ .Liquid de h.__rf -______Capacity--- ------------------ Disposal F' Distance from nearest well _ ____4D'stayce from foundatio _____ ____Distance fo nearest I e_�6/-_.. Number of lines__________ ength,of each line______ __. •r�..Width of trench____ ' PP Type of filter material___ _ _ _;Depthjof filter material-__._L_ ---_____Total length I._____ -- - See a e Distance to nearer well---`___�_________Das anile f fou anon___ _` ___. P 9 #d-� _Dis jpnce to nearest lot Number of pits-- ------ Lining ymater al. Size: Diameter--,-••---------------Depth-----2_10-�--------- Cesspool: Distance from 'nearest well_____-------- Distance from foundation--------------------Lining material-------------------.----------...... _ ❑ Size: Diameter--------------------------- - ---Depth-- ---------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well +_I _ ______}---------------------. stance from nearest buiHin Distance Distance to nearest [of line---------=------- ---- ------ � I Remodeling and/or repairing (describe)________________ r r ----------------------------------- ----•---------------------------------------•-••---•-----•---•--------••---•-------.. ----------------------- ----------------------------- ----------•-------------__-------------.---...-----------•------•------1-`-----=---------•-------•------------------------------..._.... #------------------------..... -----------------------------------------------------......--------------------------------------------------- - i t ---------•----- ----- ------ ---------- -- - ---- - I hereby certify that I have prepared this applica#ion and that the work will be done in accordance with San Joaquin County ordinances, State I s,: nd rules and regu tions of.th San Joaquin Lo al Health District. { r (Signed) 1 and/ Contractor) =-� -------- ------------- By ------------ BY----- ----=--------• ------ ------------------------------------i-- (Title) - --- ---------------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ---- DATE------------ -- ------------- REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------- DATE__._ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE'------------------------------------------------------------- Alterat'ons and/or recom endations---------- -------------------- ------------------------- ----------------------------•--------- -•--------•--•------------------------ { .• _ a ; _._...� ---------------------------------------------------- - ----------------------- -------------------------------- -- - ------------------rd -------- ---`--------------•- ---- ---------------------------- I - -------------------------------------------------------- --------------- FINAL INSPECTION BY. ------------- Date---gbtic�------------------------------------------- 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 i ES-9-2M B-51 Revised W-2100 • ,