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[ APPLICATION FOR SANITATION PERMIT Permit No. .el.;-Y_ 1 � `++� / (Complete in Duplicate) , S Date Issued pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. its application is made in compliance with County Ordin e No. 549. JOB ADDRESS AND LO.OATION--- ------------------------ ------------------------------------------------- Owner's Name-- - - ----- r------- ---------------- ------------------- . Phone/tr-_T!`-------------------- Address--- -- ---------------------------•--------------------------•-•----•----------------------------------------------- Contractor's Name „ •---- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/__ Number of bedrooms el'__ Number of baths .+!__ Lot size _®_________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobA� Hardpan ❑ Previous Application Made: Yes ❑ N0 New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep • Tank: Distance from nearest well-----------------Distance from foundation--------------------Materia#______.________.-__-___.____-______--_-____.____. , j No. of compartments---------------------=----Size-------------------------------Liquid depth--------------- ---------Capacity------------------ Dis ,sal Fie Distance from nearest well_________________Distance from foundation--------------------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-----------------_-----------------------. Seepa e Pit: Distance to nearest welL._._ 7.-_-----Distance from f undation___ Q______.D�stance to nearest lot line-___fir- Number of pif5-.-----1-------------Lining material _�_ (_.__.Size: Diameter____,G......f------Deptn--------- ------ .Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- N ( El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------- ---------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------_------ ❑ Distance to nearest lot line------------------------------- ----------- - ---------------------- -------------------------------------------------------------------- A , Remodeling an r r airing (describe):--� y/ - - --•-•---- - E ------------- ------------- ---------------------------------------- -----------------------------------------------------------•--------•---------------- --------- ---------- -------- --------- I er'by certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc to s, d rules a r ulations of the San Joaquin Local Health District. (Signe -•-- --- --- -- ::..-- --- - ------ -- --------- - - ---- ----- (Owner,andoYrContractor) By: Title t �_---�---------- (Plot plan, showing size of lot, bcati-- of system in relation to wells, buildings, etc., can be p abed on reverse sid FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------- - -- --------- -------- ----------------------------------------------- DATE--- �--------------------------------------------- REVIEWEDBY-------------------- ----------------------------------- ----------------------- ----------------------------------------- DATE------ -----\_�------------------------------------------- 16SUILDINGPERMIT ISSUED----------------------------------- ----------------------------------------------- f D TEi----------- ----1-- ------- ---•-- - Alt rations and/or recom endaf ns:------ -----a------- ..... - S re ' ------- - ---------------- ---------------------•---- - --'----------------------------------- ------- ---------f t� r - ----- - --- -- -' e .s FINALINSPECTION BY------------------- ---------------------•-- ------------ Date..lo__ `± ------------------------------------------.__. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, Califoia Lodi, California Manteca, California Tracy, California ES---9-2M 10-52 Revised W2100 - -