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v� O APP ATION FOR SANITATION PERMIT Permit Na. tet'/-----------• { r�� L (Complete in Duplicate) Date Issued Application 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 Ordinance No. 549. JOB ADDRESS AND LO ATION ��--------------------------------------•--------------- --- Owner's Name ` ------------------------------------------------------------- Phone- �D _ l Address----------------r�Z -.�F.._.------- -_ - ____ ) Contractor's Name-------•-•-- ----- --------- ----------------------- -------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial F] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number of bedrooms -01!77NIumber of baths I---- Lot size --------- •- '---- Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan%E1, .. "' Previous Application Made: Yes ❑ No $., New Construction: Yes K 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-___--l_Q_-_-Material_______ _ ___ _--_--___ -_-------_--- CyNo. of compartments-------_�--------Size-_ uid depth_- . -- ------_--_ ci __Liq a DpIsal _. Field: Distance from nearest well____.--.--� -Distance from foundation---� f.----Distance to nearest Iodine-_--- -___- ? Number of lines-----------uhf-_�`----_-__- Length of each line___-------� _j�_-__-.Width of trench----__ _---__�__------_-_- ` Type of filter material- Depth of filter material------ e-----------Total length------ -------------------- Seepage Pit: Distance to nearest well-----__--------------Distance from foundation-------------------.Distance to nearest lot line_---_-_---__----_ g Size: Diameter Depth - -- ------- 1 l Distance from nearest well-----------------Distance from foundmaterial1 ❑ Number of pits---------------- --- Linin materia----------------------_ anon Lining -------------------------Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------9ais.� Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------.-------------------------.------- ❑ Distance to nearest lot line---------------------- - - ----------------- --------------_------------------------__--------- --------- Remodeling and/or repairing describe - ------ --------------- - ----- --- - . -------------------- ••-•- --•- -----------------------------------------------------------------------------------------•------------------------- -------•-•---------------------------•--------------•-.----------------------------------•---------------------------------------------------•-•-------- 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. l•¢—CJ� -------------------------------------------(Owner and/or Contractor) (Signed}----- ...... - �-------- - 1- By:_--------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------- ---- (Plot 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 BY----------lxl/------± --- - ---- - ---------------------------------------------- DATE------ c.h ----------- ----------- . ---- ------- ---REVIEWED BYDATE . BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------- — DATE Alterations and/or recommendations----------------------------------------------- ----------------------•------------------------•------------ ---------------------•----------------------------- ------------------- -------------------- - - ----------------------------- ------------------------------------------ --------------------- FINAL INSPECTION BY:----- ---- Date---- --------------------------------------- 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 8-51 Revised W-2100