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/j APPLICATION FOR SANITATION PERMIT Permit No. _-- -CI ---- �� ? � &.-P—�(gpmplete in-Duplicate) Date issued /T4 plica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. application is made in co mpliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--- - --_- f _ Owner's Name ------ -- --- ------ ---------------- - --- Phoner-------------------- Address... - - Add ress------------- Contractor's Name----------------- r `1ti ----•--------------------------------- ----------------------------------------------- Phone 'Tnstalla+ion will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ _ Number of. living units: -____-- Number of bedrooms ---I-_ Number of baths - of size __----- -`------ ..-•------•_ � r I Water Supply: Public system ❑� Community system ❑ Private ep to Water Table -------- ft. .. Character of soil to a dep+h of 34eet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®..HS-rdpan ❑ ' Previous Application Made: Yes,❑ No ew Construction: Yes [ da❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public sewer'is available within 200 feet.) 1 Septic Tank: Distance from nearest well--161--------Distance fr foundation----/_0.-!----.Material__-P ,OV ---�___- No. of compartments---------- Ga acit "" Size p------ -----Liquid depth- ------- P Y----- �`' Disposal Field: Distance from nearest well__ _. Distancrf bn4oTlfSdation-__. - - _.Distance tp neares Number of'lines------------- �`� _Length of each line-�4-' _ Width of trench - -__-- � s� Type of filter material.-7,,- �_ -_ ._pepth of filter material--� '_-_--_______Total length----- - --f_� ^-- : Seepage Pit: Distance-to nearest well___---------------.---Distance from foundation--------------------Distance to neare ❑ Number of pits--'----------------Lining material-----------_-----------Size: Diameter-----------------------Depth------------------ e- Cesspool: Distancelfrom nearest ---Distance from foundation------------------- Lining material-__----__ Sze: Diameter # ---Depth-------- --------- ---- -- Liquid Capacity- --- _ � - Privy: Distance from nearest well --------#------------------------ -------Distance from nearest building ----- ❑ Distance to nearest lot line ------ Remodeling and/or repairing (describe):------------------------- ------------------------------------------------------------------- -------------------------------------------------- --------------------------•----------------------------------•-----•------------------------------------ --••---------•------------------•------------------------ - -----------------------------------------------------------------------------------•-------------------------------------------------------------------------------------•---------•---••----------------------------- ---- 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. -------- ------------(Owner and/or Contractor) By:----•------------------------------------------- ------ -----------------------------------------------------------------------:-(Title) ------------------------------------------------- ------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed,on reverse side). r ± FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- _=' DATE ' REVIEWEDBY = = _ ---------------------------- ------------------------- DATE ; BUILDING PERMIT ISSUED-----s ----------------------------------------------------------------•-•---------------------- --- DATE---------------- Alterations and/or recommendations:---------- - - - A -------------- - "__ - - _- -----._,- - - _ ---------- --_--_ - - __ ---- . �. - •-- ..-. ------ --- - --------------------------- -----------------------------------------------------'-...- - - --_-_•--- "' .__-' ----------- ------------------------_.----------------_...- .r-- -. / ----- -- --------------------- - E FINAL INSPECTION BY:------ _ - pate J # 1 ) --/ . ----------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California U-9-2M Revised W-2100 1.