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•� '. 1/ APPLICATION FOR SANITATION PERMIT Permit No �s* (Complete in Duplicate) Date Issued ` Application is herebymade to the San Joa qum Local Health District for a permit to construct and install the work herein described. This app lffication,is. ade-i ,comp lance with County Ordinance No. 549. F J& ADDRESS AND LOCATION_ Owner's Name----------- -------- --- --- -- Address--------- � --------------- JContractor's Name / -------- ------- Phone_ "s Installation will serve: Residence Apartment House ❑ Commercial Trailer Court❑ ❑ otel ❑ Other ❑ 1 Number of living units: _/---_-- Number of bedrooms -;k--- Number of baths j---- Lot size __ _ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ____ ___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam E] Clay El Adobe ardpan Ll Previous Application Made: Yes E] { No [ New Construction: Yes to ❑ 6 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Sept❑icAk`- Qistance from nearest well________________Distance from foundation______ r o. of compartments -.Material------------------------------------------------ � Size-------Size d'epth--------------------------Capacity----------------------- b Disposal F d: Distance from nearest wei)N: _e------Distance from foundation ------------ -_-Distance to nearest IotJine_ _____ Number of lines__ - Length of each line-_31- --.Width of trench___ Type of filter materials• _ �___ epth of filter material__ D -- ---------------Total length----7-19----------------------------- Seepage Pit: Distance to nearest well_____________________Distance from foundation-------------------.Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-------------- Size: Diameter Depth ------ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material_______-_-_____-___-__- -------------- X-MZ . ❑ Size: Diameter--------------------------------------Depth----_-----------�------------------------------ Liquid Capacity-------------------- -----gals. ;.�:. .V Y :MZ. . _ q p tY Privy: Distance from nearest well _ '-^Y'` ��""'°'" — — . . --�-_ __ _____Distance from nearest building Distance to nearest lot line __ ---- ---------------- ---------- Remodeling and/or repairing (descrila - --- --------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, nd rules an& egula 'ons of the S �oa in Local H Ith District. (Signed)- �`� A't �- � _(Own and/or °ontractor) By. _ r ----(Title------ (Plot ----- - --= --- ----- plan, showing size of lot, location of system in relation to wells,-buildings, etc., can be placed on reverse side). µ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- REVIEWEDBY - -- - ------------------- -------------------------------------------------------------- DATE_ ------------------------------------------------- - -------------------------------------- ---------------------------------------- DATE----BUILDING PERMIT ISSUEDR - __ ---------------------------------- -------------- DATE------------ S*Alterations and/or recommendations:_ ` ----------------------- -------------------------------------------------- -- FINAL INSPECTION BY:____________ / -,2 ----- ----�--.��------- -------- Date-------------------- -- SAN.JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" 5}teat Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100