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5� APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued k 4 Application is hereby made to:the San Joaquin Local Health Distri for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance N 549. JOB ADDRESS AND L TION --/-- --/- ----- --- --------- --- ------- ---- --- -------------------------�'. -------------------- ' - Owner's Nam ------ I Phone - 1 Address -- --------- -- -,h -- ------- -----------------------------------------•---•---------------------------- ----- ------------ - - -- - - Contractor's Name..------ .. ------------- Phone �.. -------------- Installation will serve: Residence A ment House ❑ Commercial E] Trailer Court ❑ Motel Other ❑ Number of living units: Number of bedrooms•_ Number of baths _ _____ Lot.'size ____ Water Supply: Public system _Community,system.Ej__,�Priv.ate_❑. � Depth to Water Talie� * r Character of.soil to a depth o'.3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay❑ AdobeY Hardpan ❑ Previous Application Made: Yes E] No� Naw Loris+ruction:-Yex No F1 I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 r,. feet.) � �__.... � S tic Tank: -} Distance from nearest well_________________Distance from foundation--------------'___.Material-----------------------__._.---------------- ____ f No. of compartments-------------- ~.-------size----------------- -- _ q Li uP Capacity id de th__.______-'_-- _ 4isposal Field: Distance from nearest well----------�_.._Distance from foundation____ -____ ____.Distance to nearest lot line_-__=_____.___- . ..„ _ ` Number oiIlines-----------------v---------------FLength of each line---------------.----------------Width of trench-----•-------------------------------- Type of file material------------------------Depth'of filter,material_-- -----_'_.-'--.'.Tot al length----_-_.---.------------------_-•-•- 1 Seepage Pit: Distance toy nearest well ____Distanc"' MfouPiaf ion_ Q.. _.Distance to nearest lot'li --Number ofi pits.-_.!_______________Lining material_ Size: Diamete'--..__-7.............Dept' _______ Cesspool: Distance of nearest well----------------- from foundation-------------- ----Lining -material___.___----------------__-___________- ❑ Size: Diame#er-------------------------- ----- Depth------------------------------- _ ----Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-..______- ----------------------------Distance from nearest building-----_______________________________._._. ❑ Distance to nearest lot line------ - --------------------------------------------- -------------- - ----------_-----_-_--- Remodeling and/or re iring (.describe) - -------- ---- -- --- -- ------- --- ----- •-- ------------------ ` M ----------- -- -- ------------- ---- ------- =-----•-- -- --- ------------------- --I- �P - 1 ___________________________________ _____ _______________ ____________________________________________________________________________________________________________________________________________________ I hereby certify tha I have prep d this application and that the work will be done .in accordance with San Joaquin County ,ordinaneeS,. Sta s, and egula ' of the San Joaquin Local Health District.. " (Signed) -g } --� ------ ------- -------------------r---- ---------- (Owner a4lor Contractor) By:........ ..... { ---rr x r 1TItl r .---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be ced on reverse sid Ail FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY DATE--------- r - = '------- �5=------------- REVIEWEDBY -------------- -------------------------- ------------------------------------------------------ DATE BUILDING PERMIT ISSUED------- -•---•---•----------------------=------------------------------------------------------------ DATE--------------------- Alterations and/or recommendations-------------------------- --------------------------------------------------------•------•------------•------------------------------•-----------------•- ---- .----- ---------t----- --------------------------------------------------- ----------------------------- _1 ... Z. --------------------- -----•---------------- $----------------------- ------------------------------------------------------•-------•--------- ------ ------------------------------ ----- - �p ` �► ----------------------------------------------------------------- ------ --------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY------ ---------------•--------------------------- --------=----- Date----------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Streef 300 West Oak Sfreef 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100