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J :ti Y APPLICATION FOR SANITATION PERMIT Permit No. __ 2L3.____-- �1 (Complete in Duplicate) f Data 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 O nce No. 549. JOB ADDRESS AN CATION! I - -------------------------------------------------------------------------------------------------- Owner's Name - • ----._ Phone---- _. .._ . Addres.- ---- - -------- ------------`- - ---- -------------- ---•--------------•------•---•-------------------------------------------------------------- Contractor's Name ----------------------------------------=- •----•- ------ Phone-_ w Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units: -/---' Number of bedrooms_- Number of baths __/--- Lot size _��____-,el" _____________________ Water Supply: Public system 'Community system ❑ Private ❑ Depth to Water Tabl(�ee::Ilft. Character of soil to a depth of.3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Ado13�v Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic`tank'or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation________:______-'_.Mater•sal-___________.______--_______-_____--.._-____-___. ---- Liquid de tCapacity Y---------------------•- No. ocompartments------ _______________Size________.-__---._ k -------- Dispos I eld: 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------------------------- of filter material____._______._.-___'__Total length___-________________________________-__-__ Seepage Pit: Distance to nearest well_ _ .__ ____ Q_�.-_.Distance to nearest lot line---- _____ Distance f m f dation__ Number of pits__________________Lining material ____ . .- -Size: Diameter-_-_,_._____-._._..Depth_ Q�______________.__ Cesspool: *Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------- Size: __-__-_____._.-___.____.- ____Size: Diameter------------------ ------------ -: ` -Li uid C— acit= als. F;r T Privy. a Distance-from nearest well-------------------------------------------------Distance from nearest building______________-_-_________ ❑ Distance'to nearest lot line------------------- ---------------------------------------- --- ----------- -------- --------------------------•---------------- Remodeling 'and/ r repairing (describe}:____-. �, ___ . ------------------------------ ------ ----------------------------------- -- ------------------ --•-------- f---- -------- ------------------------------------------------------ --------------------- -----•--------------------------- --•------------------------------------••-------------------------------- ----------=-------------------- --------------•-- --------------------•--------------•-•--------------------------------------------------------------------------------------- ------- -•------.. I hereby c ify that ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, nd ules and regulations of the San Joaquin Local Health District. (Signed)--- - ---- --- ---------------------------------------------------------------------- ----- caner an jContractor ) ITitle By:----------------- _ a ( ) •---------- {Plat plan, showing s ze of lot, location of system in relation to wells, buildings, etc., can-be plate on rev side x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ---- ------- ----- ----- --- ----- ---------------------------------------- DATE--------------Z1, REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------------•------ - BUILDINGPERMIT ISSUED----------------------------------- ------------------ -------------------------------- ----------- DATE------------------------------------------------------------- Alterationsand/or recommendations------ ----- -------------------------------------------------------------------------------------------••---------------------------------------------------- ----------------------------------------------------------------------------------------------- ---- --------•--------------------------------------------•--•------•-----•-------------------------------------------------- ------------------------------I----•------------••---------------------- --------•---------- ------------------------------------------------------------------.....-------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ...------------------------------------------------------------------------- ------------------------------------------------------------------------- /Q FINALINSPECTION BY--------- ----- ----------------------------------------------- Date------------------ --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT l 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r . ES-9-2 M! ; Revised W-2100