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fi APPLICATION FOR SANITATION PERMIT Permit No- ----- ®-- r; I (Complete in Duplicate) Date Issued ________ 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 Ordinanc No. 549. JOS ADDRESS AND LOCATION-------- �---- _----- -- !------ - ------ -- '` -----------------------=--------------------------- Owner's Name---------- f/ ,lx!- --------------------------------------------------------------- Phone------------------------------------ Address--------------------- �E = - -------------- - one Contractors Name_______________ ----I - Ph Installation will serve: Residence' [Apartment House E] Commercial E] Trailer Court ❑ Motel E] Other El.Number of living units: __---- mber of bedrooms _ _.__ Number of baths _/___ Lot size _____ _ __ _1- --------------------- Water Supply: Public system Community system ❑ Private ❑ Depth.to W6ter Table -------- ft. L Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Cko<arclpan ❑ Previous Application Made: Yes ❑ lNo *-N ew-Construction. Yes [ lO ❑ 3 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public se is available within 200 feet.) Septic Tank: Distance from nearest wellal[(Q_�___ istance from foundation_/f---------- M0e. ia E/` No. of compartments---4---------- eJr� �: Liquid depth �� Capacity '``/� O Disposal Field: Distance from nearest welA& _ Q--------__Distance to nearest Iodine__ __________. istance from foundatio Number of lines_____�7AV�_____ _.__ Length of'each line------ ___________________Width of trench______ Type of filter material_�'e2 _-Depth of filter material_` -----------Total length___-__- 1l Seepage Pit: Distance to nearest`well----------------------Distance from foundation____.______________.Distance to nearest lot line_________________ ❑ Number of pits--------------------Lining material Size: Diameter --------------- Depth I Cesspool: Distance from nearest well-----------------Distance from foundation-----------.--------Lining material_________________________----------- . !A ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity------------------�----gals. i Privy: Distance from nearest-well------______________________-______-------------Distance from nearest building______________________-_---_____________- ❑ Distance to nearest lot line - = -------------- ---- ---------- -- -- --- Remodeling and/or repairing (describe)_______________ __ _ ' ------------------------------------------------------------------------------------------------------------------- x ___ _ ----------- ------------- ------------------- ----------- 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.. -A-------- [Signed)---------- ---••'�--�6•-�-- -- -�-� -� - ---- --- -------- -�------------- - =-- - -----[Own and/�Contractor) B ------ ---- -----------------------------------(Title)---- ------------------ r (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). s = ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------t =_ BATE - z,a = REVIEWEDBY ------------------------------------------ DATE------ ---------------------------- BUILDINGPERMIT ISSUED----------------------- -------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:--•------------------------- ----------------- -------------------- ---------=-------------------------- ------------------------ - ---------- , f _______________________________________________ __________________________________________________________________________________________________________.__-____ ` ------- ---------- FINAL _____-__-FINAL INSPECTION BY-------------- -J' ----------------------------- Date 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 LS-9-2M 8-5I Revised W-2100 {