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s APPLICATION FOR SANITATION PERMIT Permit No.•�� _..34A-•-`----- (Complete in,Duplicate)[ p P ,} � . Date Issued rein descrid. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hebe This application is made in compliance with County Ordinance No. 549. /-4s JOB ADDRESS AND LOCATIO -.---"-."-d"""� .-- --- Phone------------------------------------ ---------- ------------ Owners ame---------------___" �+----------------- --- A Address-------------------------- ---•-------- ------------------ -----------------------•------ Phone----------------------------------- --------• --- ------------------ Contractor's Name--------_-------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms .:_"-___ Number of baths -------- Lot size -_------•_----__--_--_-----_ ------------------------------- Water Supply: Public system ❑ Community system ❑ Private-❑ Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet:'-Sand F1Gravel ❑ Sandy Loam E] Clay Loam E] Clay [j Adobe❑ Hardpan ❑_II Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No El l 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----.-----_- Material ---_-.-----------------.-----------.----------- " No. of compartments Sixe Liquid de�h--------------------------Capacity..--------------------- Disp❑osal Field: Distance from nearest well-.................Distance from foundation_____________._.__.Distance to nearest lot line--------_------- ❑ Number of.,lines- 'Length of each line- A------Width of trench----------------------------------- Type of filter material------------------------Depth of filter material---------------- -----Total leng#h_-"_____.______•----------- I w --_Distance from foundation___________________.Distance to nearest lot line___ Seepage Pit: Distance to nearest well-.-----_----- ❑ Number of pits Lining material-----------------------Size: Diameter-----------------------Deptn-------------------------------- Cesspool: Distance from;ne rest wel -1I'YG '-.Distance from f undation.. _Q-'`Linin material.__ _ `� _ _De th; w --------------------------- -------Liquid Capacity ''"f' -gals Sizc:.Diameter-_- -- -- p Privy: Distance from nearest well_.._---- --------- Distance from nearest building " Dis#ante to nearest lot line-------------------- -------- ------------------------"-- ------------------------ Ra---------- � i Remodeling and/or repairing (describe): - --- •---------------------------•--------d •--------- - s - c --- :- ---------- 4r-- - 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. �...�.." ------------------------------------------- (Owner and/or Contractor) [Signed} _ -- --------------------------------(Tit1 e--------------------------------------------- -------- ------ [Plot plan, showing size of lot, location of system in relation to wells, buildi igs, etc., can be-'placed on reverse side]. FOR DEPARTMENT USE ONLY ------------- DATE---- ------------ APPLICATION ----APPLICATION ACCEPTED BY-------------------------- --- ---------------------------- ----- - - DATE_--------------------------------------------------------- REVIEWED BY----------------------------------------- -------------------------------------------------- �;--- _ .. - .� ... _ __ _ _ ______ _ _ DATE--------------- ----- --- BUILDING PERMIT ISSUED------------------------------- Alta tions and or re mmendations:- ------- - �-_ .._ -----� ------�-- ------ ----- ----------------------------------------- r • _ _ __ _ _ _.-_ � - -----------\_ ------ ' 1=1NAL INSPECTION BY----------------- ------------------------------ - --------------- Date.-------------------- ------ ------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 5 camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y Stockton, California Lodi, California Manteca, California Tracy, California r ES-4-2M 10-52 Revised W-2100