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. 3 0 Perm � APPLICATION FOR SANITATION PERMIT it No. __ (Complete in Duplicate) or 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 LOCATION � ----------- ----------------------`--------------------------------------- Owner's --------------------------------------Owner s Namew �� Q Phane ------------ qq _ ----------------- " - Address------------------)-�- ------------ ------ Contractor's Name----------- -------------------- ---------------- ------------------------------------------------------------- Phone---------------------------•------- Installation will serve: . Residence Apartment 'House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --umber of bedrooms-.2--- Number of baths I____ Lot size --- -------------------------- Wafer Supply: Public system ?❑ Community system ❑ Private ET----Depth to Water Table,;�_d ft. Character of soil to a depth of-3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑, Clay Loam ❑ Clay ❑ Adobeiardpan ON Previous Application Made: Yes ❑ No New. Construction: Yes 21'*No .❑ TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `1/ Septic Tank: Distance from nearest well_4__�_........Distance from foundation_��------------Material- --.-=,�--------------------- No. of compartments------_`+�r---------------Size-_9.X_Y,-,x3_----------Liquid depth------) Capacity... ---------� ------------ _ � � Disposal Field: Distance from nearest well__4a--*.......Distance from foundation__`-6---______---Distance to nearest lot line ___________ []/ Number of lines_______________________ ____ Length of each line---JI-a__,_------------Width of trench----- 7Y_____-------,-------- Type of filter material__--- ---Depth of filter material---)__g _____________Total length_-_l_k4-.-------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------.-----------Distance to nearest lot line.--____.________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------------------------------.Dept --------------------------------- Cess ool: ------------•------•--.....-- Cesspool: Distance from nearest well-----------------Distance from foundation------------------..Lining material_____---_---_________-________...._. ., Size: Diameter - ----De Depth -------- _T _ -L-igaidTC- acitY=_ = R.,�'Tis.` -T t .. ---------------------------- Ming-----• •- may: Distance from nearest well------------------------------------------------Distance from nearest building--------------------------•--------------_(� Distanceto nearest lot fine------------------------------------------------------------------------------------------------------------------ ------------------------ g and/or d (describe):-------------------------------------------------------------------------------•----•------------------------------------------------------------------- /or re pairing g �- ------------- --•---------------------------------------------------------------------------------------=----•------- -------•--- ------------------- --- - --------------•-•-----•-•---------------•--------•--------------------------------------•----------------1---------------------------•--------------------------------------- ------ -------------------•--------------------------------------------------------------------------------------.------------------------------ ------------------------------------------------------------------------------------ , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County� r' ordinances, State laws, and rules and regulations of Al, San Joaquin Local Health District. �� = ---- ---------------------- ------------------- --------------------- (Owner and/or Contractor) -: .-. Tale (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------- ------ ---------------------------------- DATE---------- = ------------------------------------------� i REVIEWED 13Y - ------------------------------- DATE --- _` f BUILDING PERMIT ISSUED. DATE--�------�-=_--�- ---- -------------- Alterations and/or recommendations----------- ---------- --------------------------------------------------------------------------------------------- ---------- ----------------- ------------------------------------------------------------------------------------,---------------------------- , ------------------------------------ ---------------------- -------------------------------------------------------- ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------------------- ----------------------------------------------------------------------------- FINAL INSPECTION BY--------- -- -- - --- -- Date-.__--- __- -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT �. 130 South American Street 300 West Oak Street 132 Sycamores=Street 814 No'tt\h "C" Street Stockton, California Lodi, California Manteca, Califoroie �racy, alifornia ES-9-2M 8-51 Revised W-2100