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r APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ Date issued Applica{ion 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 Ordina ce No. 549. JOB ADDRESS AN ATION. --- -- -- ----------------------------------•-------- -----------1— . Owner's Name- --- --------� - -- ----------•---------------------------------------- --- -- ----------------•---------- --------- Phone-_-.: � Address-. ---- -----= •-----•-•-- -- ----•----------------------------- ` Contractor's Name--- - - - -- ----�--------------------------- --------------------------------------------------•-----------------------._.._ Phone----, Installation will serve: esidence�$ Apartment House ❑ Commercial. ❑ Trailer'Court L] Motel ❑ Other L]Number of living units: ----{ Number of bedrooms --,2--.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 fee+:. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes E❑ No New Construction: Yes,( es No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T nk: Distance from nearest well__;__________.__Distance from foundation__________________.Material______.._______.__.___.._____----______...___.__. �J No. of compartments--------------------------Size------------------------ -------Liquid depth--------------------------Capacity----------------------- Dispo F- d: Distance from nearest well-----------------Distance from foundation_______•-_:___•___.Distance to nearest lot line_________________ Number of lines-------------------.---------------Length of each line-----------------------------,Width of french-------------------_-------------- Type of filter material_________________.:____Depth of filter material-----------------------Total ler gthc_________________-_.___-_-----_________._ p Number of ifis___ .. - 1��-' � , See a e Pit: Distance to nearest well-. Distanc�om f� ndation____ Distance to nearest lot line_______- 1 fs P / .-_--_.------.Lining material- -- _�---Size: iameter__ ------------Depth_----�J __: ------ Cesspool: Distance from nearest well-----------------Distance from foundation Lining material_____.____.._____._________________- ----- _Liquid Capacity ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------- q --------..------------------gals. € Priv Distance from nearest well-_'.:._' '....____.__ Distance frofn nearest building ❑ Distance to nearest lot line------------------------------------------------- - -----••-• ------ ----------------------------------- ------------------------------- modeling and/or _repairing (des e) C z -- ------ --- -- - --- -�----- -- •-----•►..--_--•. --•--/ -- - •------- -------------- ------------------•------ ----- ------- ---- - ------------- ------ -- ------ ---------------------•------ ---------------------------- ---•--- --•---------- --------------'-- -_Fti-------------- --------------------------------- --------- ---- --------------------------- -------------------------- ------------------ -----------------------------------•-------------- ------------------------------------------ I hereby cert' y that I ave prepared t application and that the work will be done inaccordancewith San Joaquin County ordinances, St laws, a r les and regu tions of the San Joaquin Local Health District. (Signed) � --- ---•--- - Owner and/or Contractor II By:------------------------ � .• = (rtle)- - l (plot plan, showing size of to+, Ico a+ion of system in relation to,wells, buildings, efc., can be pla d o everse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. ----------------- --------------------------------------------------------------------- DATE-------------------•------------------------------ REVIEWEDBY-------------------------- -- -5:—-- -------------------------------------------------------------------------------- DATE---•��L-------------.---- ------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE--------t -----------------------------------------•----- AIorations d/ r reco ndations:--- ---- ---_--- -------:W___ -------------- �y-f ------- ----- ----------------------- ---------•--------------------------•---------------------------------------------•-----------�------............_.---- - - - - ------ ---------------------- ------------------•------------------- ---------•- ------------- - ----------------- - --------- ------- -- -- --•----------- ------------- --------------------- FINAL INSPECTION BY:. = Date ----------------------------------------------------- i 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 145446 A-w - 12-54