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S� Permit No. __iJ.�` � �m r APPLICATION FOR SANITATION PERMIT '_ - ------- i (Complete in Duplicate] ( Date Issued ______Application _�_ Y is herebymade to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thiapplication is made in compliance with County Ordinance N . 549 JOS ADDRESS AND LOCATI %.-.- - ------ ............. -•-•--------------••-------------- ._... -- ----------------- Owner's Nam !�'il�- ----- - ------------- ------------------ -------- Phone. Address---- ------------------ ------------------- --•---------------------------------------------------------•-------- -------------------••---•-------------------- Contractors Name--------------- -- /-... --------------------•------------------------------------------------- ___ Phone_"7_.-_: Installation will serve: Residences Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -/�___ Number of bedrooms Number of baths .--- Lot size _ 1'��J -,�-�� --------------- Water Supply: Public system ommunity system ❑ Private ❑ Depth,to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ AdHardpan ❑ Previous Application Made: Yes ❑ N94< New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permittediifpublic ewer is available within 200 feet.)Septic Tank: Distance from nearest w ___ Distance fro found tion______- Materal_ ----------- _ ' i '"No. of compartments__--- -_-_ ---Size- ___-, z-.�Lquid dep -- ---�---------Capacity__-- - pisposal Field: Distance from nearest well-.._______- --.Distance from foundation--------------------Distance to nearest lot line----------------- El Number o•i lines--------------------------- -------Length of each line----------------------------rW'dth of french----------------------------------- Type of filter material________----_--_._/Depth of filter material----------------_______Total length_----_________-.______--_---�--j---. �+ r Seepa a Pit: Distance to nearest well-d—.. -.5p-Distance from�fou'Adation_-_-,7----------.Dist7nce to nearest lot li e_________________ ,Lining materielrc-�-� -Size: Diameter--- Depth ,� -------------- Number of pits------- ----------- } 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----------------------------------------- El Distance to nearest lot line-------------- --------------------------------- -- Remod in and/or re airing (descri el:--- ------_ -- -- - ------•----------------------------- __ ----------------- ------------------------------------------------ --------------------------------------------- --•------------------------------------------------------------- --------------------•--------------------------------------------•------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat a , and end regulations of the San Joaquin Local Health District. ----{Owner and Contractor ti . (Signed)-- ------ By:. = -------(Title}--- - `� (Pla# plan, sho ' g size of lot, location of system in relation to wells, buildings, etc., can b`placed on reverse si eI. �-- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--.- DATE-----------•------- --------------------------------------- DATE---1 `" REVIEWEDBY --------------------- -------------------------------------- �c '� BUILDINGPERMIT ISSUED--------------- �� ` ------------ --•-------- . DATE- /--------------------- -------------------------•------- Alterations and/or recommendations-------- -- ----------- ---------------------------------------------------------------------• ...--------------•--.....•------------------------------ 1 ----------------- ------------------------------------------------------------- ------------------------------------------------------------------------ --------------------------------------- FINAL INSPECTION BY: ---------- - --•---- - - Date ,f-.- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California ^ Lodi, California' Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100