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'Lb APPLICATION FOR SANITATION PERMIT Y Permit No. .._f -__-_ -------- (Complete in Duplicate) Data Issued . �__ Ste~ Applicaa-ion is hereby made to the San Joaquin Local Health District for a permit to onstruct and install the work herein described, This application is made in compliance with County Ordinance No, 549. / r JOB ADDRESS AND LO TION. --�a .. r•-- - --- -- ----------- -------------------------------------------------- '0 ------------------------------------------------- 2 14 Owner's Name � .� Phone �_. _ . "� Address--- --- •r.�-.� ---•- Contractor's Name____.._.______.__ _ - ---- s ------ Phone--,--- a Installation will serve: Residence Apartment Hesse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. ____ Number of bedrooms-,e9- - Number of baths __/___ Lot size . a., .2Q--------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table "ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ NOX New Construction: Ye!,�r No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ptic Tank. Distance from nearest well_________________Distance from foundation--------------------Material---------______.________--_________.__________- No. of compartments--------------------------Size------_---------------------..Liquid depth--------------------------Capacity-------------------•--- Disposal Fie Distance from nearest well-________________Distance from foundafiion--------------------Distance to nearest lot line----------------- Number of lines ---•-------------------------------Length of each line---------------------------.--Width of trench.-------------------------------•-- Type of filter material-------------------------Depth of filter material----------------------_Total length-______________-___---____________________ See e Pit: Distance to nearest well_r71.59-______Distance fr foundation___e G---___.Distance to nearest lot line___.��___ p g ry --------Depth-. �- k Number of its.__._-�---__ -_ ___Linin material ,�c�'r,�-� Size• Diameter__..__.__� Cesspool: Distance from nearest we11-----------------Distance from foundation--------------------Lining material____-___________________-__________. ❑ Size: Diameter----------------------------- -------Depth_---------------------------------------------------Liquid Capacity---------------------- gals. Privy: Distance from nearest well----------------------------------..._-_---------Distance from nearest building________-__--._________________________.. \ ❑ Distance to nearest lot line ----------------------------------------- ----------------------------- r • Rem eling a d/or repairing e cribe):- ----_w.t � = �� _- � ..E-- --------------.------- r�' ---•-----•--•--------------------------------------•----------•-------------•-------•--------------------------....----------------- ------------------ ---------- V ___________________________________. ._________-___ _-____________________-___________-____•---__-______-____________.____....._.__._--_-_-_._.-__-________-»__________________________________-________-__-_._______---__-__ 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,ales and regulations of the San Joaquin Local Health District. (Signed: ---- ----------------•---------------------------- (Owner,andd/.or Contractor SY� _--------t-:-r-- (Title] (Plat plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B - - -------------------------------------------------------- DATE------------------ --------------- ----------------- -- --------------------- REVIEWED BY = DATE ----- ------ BUILDING PERMIT ISSUED----------------------------------------------•--------------•--------------------------------------- DATE-- -- ------ - ---------------_---.-- --- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------.------------------------------- ----------------------------------------------------------------------------- ------------------------------ ------------------------------- ----------------------------•--------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------•-- FINAL INSPECTION BY: Date ---------�-------- - ----------------------------------- SAN - ---------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sheet Stockton, California Lodi,-California Manteca, California Tracy, California .E5-9-2M ; Revised W-2100