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APPLICATION FOR SANITATION PERMIT Permit No.d. -�--- - II ' (Complete in Duplicate) (c, Date Issued - - - --- r 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 Ordin nce No. 549. ' F JOB ADDRESS AND L CATI �__ _____/__ _ --- ------------------------------- = Owner's Name - ------- I Phone---__--'---------------------------- i I , Address._ -- ----- Contra'ctor's Name---------• --- ---------- --- --------- -- --------- ------------------------------------------`-------------------- Phvn $.-k710-07 ---p�-•7 Installation will serve: Residence --Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ C Nu* ber.of living units:!---/--- Number of bedrooms _4._ Number of baths --/---- Lot,size _`_X__L_d d r Water Supply: Public system" �ommunity system ❑ Private ❑ Depth to Water.Teble_�O'ft. ,. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er--Hardpan [❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ! Septic 'rank: Distance from nearest well________________Distance from foundation--------------------Material------------------.__:________________.._____- • iP. ❑ ;� No. of compartments------------- - ---•- - --Size--------------------------------Liquid depth----------- -------- ----Capacity----------------------- �. Disposal Field: Distance from nearest weft-----------------Distance from foundation--------------------Distance to nearest lot line----------------- J (� Number of lines-----------------------------------Length of each line-----------------------------.Wicifh of trench--------------•-------------------- 1a1 ElNumber of filter material-------------------------Depth of filter material------------------------Total length-------------------------�- ------_-_Q-_-_-_-_-_-_ -_- fJ ' -T_ _I� t } e ✓ See a e it: Distance to nearest well----- r_--------Distantf om0?oudation___ ._____.Distance to nearest lot line__ Number of pits_ ------------ Lng material - -Size: Diameter �3-- --------Depth Cesspool: Distance from nearest well-----------------Distance from foundation___._.--------------Lining material__.__._____________________i-________ Size: Diameter___- De th __-__.__Liquid Capacity ❑ -----------. ""o - q P tY gals. Privy: Distance ;from nearest well------------------ Distance from nearest building____- ----------------- r _- _-_..._. Distance`to nearest lot'line--------- _ "" _"'"" --------------------------------- ------------------------------------------------------------------------------ �il ' 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, r -- -- � =i - and/or Contractor (Signed.. t �Y� ------------------------------- '--(Title}--- ------ --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., cavi be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- ----- ---------------------------------------- DATE----------- f u REVIEWED BY---------- -------------------------------------------------- -- -------------------------------•---------------------- DATE--------------------•---- ------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------•-------------------------------=----------------------- DATE------------------------------------------------------------- Alterations and/or recommeoclations: -----------------------•--------------------------------------•-----•-----------------------_------------:._..----•- ---------------------------------------------------•----------------------------------.---•--------------------------------. ------------------------------------------------------------------------------------------- ---------------------------- - -------------------•--•----------------. FINAL INSPECTION BY:---"--'. _ S _ L Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stteet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : Revised W-2100 K .f