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.41 eg APPLICATION'-oFOR SANITATION PERMIT Permit No. �f {Complete in Duplicate) Date Issued � _ 17 A plica4ion 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. i JOBADDRESS AND LOCATION --------------------------------------------------------------- -------------------------------------------------------------------- Owner's -- ------------ ---------- Owner's Name-=------------- ------ ---- -------- --------------------- Phone-- - ------ Address------ ,l � --- --------------------------- ----- _ 1 Contractor's Name----- - --- - - ------------- -,------------ --- Phone-- _ Installation will serve: Residence [R—Apartment'House'❑� C6mmercia`I'❑"TraiI4F,Court E] Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms _.�Number-of baths. -___ Lot,size ___f�-� � -s^------_________________- Water'Supply: Public system Community system ❑ - Private ❑�&pf t {Water Table' ft. Character of soil to a depth of 3 feet. Sand ❑ 1 Gravel ❑ Sandy Loam Clay Lam ❑ Clay ❑ Adobe .Hardpan ❑ Previous Application Made: Yes ❑ No New Construction':. Yes No ] TYPE OF INSTALLATION `AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) { f eptic Tank: Distance from nearest well--------------Distance from'foundation_"'"!_____"_.'__.Material---------.________________;______.._ ---------------Liuihdr Disp�o,.,sarl field: Dotance from est well-/��_.._.Dlistance:from foundation df pth��'---------------__--------Capacity----!___________________ e r f -r_ td _,-_-Distance to nearest lot line___�s_� L� u-mber of lines matena-_r___----_- Length•-of ea�h line_--------�-._-t_______ ____W.idth.of trench____�_z�,•.--------_-------__- � eT ----De th of filter material___/e_f/__°..,__Total length_`__.2, `_-----i--------=-------- !v� Seepage Pit. Distance to nearest well_ ? ___`Distance-from-foundation- Q________4Ditance fo nearest of line__: _Linin material_ �"�Size: Diameter----��-r ��-------De Dept h of pits---_-,::�`---___--- g• P --- Cesspool: Distance from nearest well____-_ "" .___Di tante from foundation...........___.__..Lining material------------- ±____, - ❑ Size: Diameter__ __-__. Depth -_ {((-- _ -- - : -'--.y{'yL----Liquid 'Capacity- _ gals. Privy: Distance from nearest well _:_ - - _*._Distance from nearest building___________________ ______ ❑ _ .Distance to nearest lot fine- --- w �---- +fir tr_ -------------------------------------------------- ---- --------- -- Remodeling and/or repairing (describe) -------------------------------=---'--------•--------- -•---- -------• --------------------------------- ---- -----------------------_-----------....-------------------------- __--------------------------------..____----------7---------------------------------------------- -------------------------.---------_,---__.------------- I hereby certify that I have prepared this application and that the work will-be done in accordance with San Joaquin County *mss ordinances, State laws;-and rules and regulations'of the San Joaquin Local Health District._ �� -�f- - ------ ------------------------------------------------------ O ner and or Contractor (Signed) ) BY� �.��.�.. - -- -- I- --- =---------- Title------ ------ ��t 2 `------------ -- = = ( , (Plot plan, showing size of lot, locatio of system in;relation to wells, buildings, etc., can be placed'on reverse side). . . .,. FOR DEPARTMENT USE ONLY APPLICATION - ACCEPTED-BY- ----=- ---- ----�---------------=-- ------- -------------------------------=-------- DATE---------- ----....----��r-_`-�___�---------- REVIEWED BY---------------------------------------------------- ---------------------------------------------- ------ DATE-----------------------------------------'------ ` BUILDINGPERMIT ISSUED--------------------------------------------------- ----------------------------------------------- DATE---:------------------ ----- -------•- =----------- ' Alterations and/or recommendations:----------------------------------------------------------------------------------------------------- _---- ' ----------------------------------------•----------------------------------_-- ..----------•------------------------------•------- .. -- ------------------------------ --------------------------------------------------•- -------------------------------- -------------------------------------- --------------------------------------------- --------- ---- --- ---- --- -- -- ----- --- ------�------------------ --------- 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, Cafifornia Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100