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�� Permit No. � L APPLICATION FOR SANITATION PERMIT l (Complete in Duplicate) Date Issued _-�.--- -------------- es - r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein des r bed. This application is made in compliance with Co11 Ordinance No. 549. *_Y__(!- JOB ADDRESS AND LOCATION____ -___ ' .-__- Phone x' Owner's Name---- -- -- ------ -- -----'--- =---- -•- - •- •- --- ......- - Address---- - ! �d / 2. .r------------------- Phone.- ----- Contractor's Name__._ _. _ __ ____ ----- ----- -----� Installation will serve: Residence. Apartment House ❑ Commjr�cial'Q _ Trailer Court ❑ Motel ❑ Other El Number of living units: Number of bedrooms . __ Numbcr of baths ---/_ Lot size _ 1 Water Supply: Public system k-'6`ommunity system ❑ Private ❑ Depth to Water Table 0- ft. Character of soil to a depth of 3 feet: Sand F1 Gravel ❑ Sandy Loam ❑Clay Loam [I Clay ❑ Adobe Hardpan❑ p Previous Application Made: Yes ❑ No 24__t,�"ew Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.] Septic Ta Distance from nearest well-----------------Distance from foundation---:---------------Material-------------------------------- No. of compartments------ -------------------Size_----------------- -------------Liquid depth---- Capacity < Dis osal F1 Id: Distance from nearest well..............__Distance from foundation____--______--____.Distance to nearest lot line_________-_______ P ----Len th of each line-----"-------- ---- Width of trench--------------------------------- Number of lines------------------------- g - - Type of filter material-------------------------Depth of filter material-------------------�-Total length-----------.----•----" f Distance from foundation___.�ff------.Distance to nearest lot line-"�-_-.----- } Seepage Pit: Distance to nearest well�� s••� • --- - r 3oNumber of pits--------/--------Linmg mate*ial_. ��-�ize: Diameter_�� -------De th"_ ie_ - {' CesspoDistance from nearest well-----------------Distance from foundation________________ -.Lining material _._--_-._____._---______ .-__. . Depth---------------------------------------"--------..__Liquid Capacity------------------------ gals. ❑ Size: Diameter----- "------------------- --------- Distance from nearest building-------- -------------------------------- Privy: Distance from nearest well------------ ----------- z ❑ Distance to nearest lot line------------------------------------------------- ----------- Remodeling and/or repairing (describe)--------------------:--- -----------------------.-------------------------:---- --------------------------- ------------------- -;------- ------------------- ------------------ a --------------------------------------- ------- ----------------------------------- _----------------------------------------- ----•------•----•-------------------------------------------------------I----------------------- 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. yet Contractor( d (T(Title) -----------•-------•------- -- -- - - -- e)------ -------- -- (Plot plan, showi size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR/3EP ENT USE ONLY 1Y DATE-------- 11 - -------------------- APPLICATION ACCEPTED BY-------------------- __ __ ------------------- --------------------------- DATE----------------------------------------------------------_ REVIEWED -•------------•---------------------- REVIEWEDBY-------------------------------------"-------- ----------------- -- -------- DATE------ --------- -- ---------------------------------------- BUILDING PERMIT ISSUED---------------------------------------------- - Alterations and/or recommendations:------- -------------------------'---------------------------------------•------------------- _I--------------_----------_---- --•------ ------ 1 -----------------•----- - - ----------------------------------------------------------- C� - --------------------------------- r/ �1 FINAL INSPECTION BY-------------------------------- -- •- r -�---•--•-- Date------ ------- -- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 5 camore Street 814 North "C" Street l30 South American Street 300 West Oak Street y Trac California Stockton, California Lodi, California Manteca, California y FC—Q-2M 10-52 Revised W-210