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_ p APPLICATION FOR SANITATION PERMIT `�� Permit No. (Complete in Duplicate) a . Date Issued _____ .1�-5- ' Application is hereby made to the-San Joaquin Local Health District for a permit to construct and install the work herein described. 1 This application is made in coFnpliance with County rdinance No. 549. JOB ADDRESS ND LOCATION. .__ � rr - -____- ------ ------- ----- ---------------------------------------------------------------------------- ^/Owner's Na ------- - , —Phone ---------------!------------- Address---------- ------------Address---------- ----------1_. r ------------------•------------------------------------------ Contractor's Name--.-- --------- --_----- Phone ------------------------ •- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] }her ❑ Number of living units:;___�_-- Number of bedrooms __ _ Number o aths __ Lot size Water Supply: Public system.❑ Community system '❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet. Sandi Gravel E] Sandy Loam ❑, Clay Loam [j Clay [:] Adobe �ardpan El Previous Application Made: Yes E] No ; New Construction: Yes El"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publig ewer is available within 200 feet.), !t Septic ank: Distance from nearest well- � Distance6rom ound tjon__ __ __________.Mategi4 No. of compartments--------__ /Q-r`-XX _Li uid de h---------- ---------------Capacity-- I t _.- Size q - -------------/ : . 1 Dispos Field: Distance from nearest wel -----------------Distance from foundation___ F-Total Distance to nearest to lin __YL Jj -------Number of. lines--_-___ _.,_Lenpgth of each line---�_ --_-- hofr nch-----��rType of filter materi e th of filter material--_----_/ length --------------- Seepage' -_-Seepage' Pit: ..Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------- __ ❑. Number of pits----------------------Lining material------------------------Size: Diameter-------------------------------------Depth-------------------.--- ------ 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___._._____.____:---------------- Distance __.._ - - ------------------- ❑ Distance to nearest lot line---------------------------- Remodeling and/or repairing (describe)-------------------------------------------------------------- _ w - ---•----------------------•------------------------------------------------------------------------------ ----------I---------------------------•------------- ------------•------------•-------•----------•------------------•-------....----------•--------•----------------••-------------------------------------------------------- Thereby certify that I have prepared this application and that the work will be done in accordance wifh San Joaquin County ordinances, State laws, and rules and regulat'ons of the San Joaquin Local Health District. (Signed)--'-.-,- - ----- ----- ------- (Owner and/or Contractor)- Plot Ian• -L= <.. ----- By: -----(Title)-------------------------------- ------- --- - -- --------------- ( plan, showing size lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY'___. 3 --------------------I----------------------------------------------- DATE------- ------------------------------------------------- REVIEWED BY ---•---- - - ----------- --------------------- ` DATE BUILDING PERMIT ISSUED------'---------- ------------- DATE----- - 'Z!` s and/or recommendations:----------=-----_- --------------- ------------ - --------------------------------- ---------------------------•---- teratiort _ --------------- ----------- --------------------- ---- ------------------------------------------------------ ---------------------------------------------------------------- ------------------------------------------------------------------------ --------------- 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, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 *+