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' APPLICATION FOR SANITATION PERMIT Permit No. ___.-_ - °? (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst th� ork Herein described. This application is made in compliance with County Ordinalce 549 �jr 9G 3 JOIE ADDRESS AND LOCA I ---------- --- --------------- Owner's Name------------------ . ------------- --- ------- -- ----- -- -- ---------------- -------------------.----- Phone �-9 _ Address----------------------1.� �-----�----- ---- --- --- -------------- --------•---------------- ---------•----------------------------------•-- ------- - ----------- Contractor's Name---- ------ -- ----------- Phone---- - .S�Z Installation will serve: Residence Apartmen# House ❑ Commercial ❑ Trailer Court ❑ Motel E❑ Other ❑ f -F'' Number of living units: -PZ-- Number of bedrooms,4f--- Number o aths �__ Lot size ___f� -- ------------------- Water Supply: Public system E] Community system '❑ Private Depth to Water Table--d- ft. Character of soil to a depth of 3 feet: Sand ❑ .Gravel E] Sandy Loam ❑ Clay Loam E] Clay E] Adobe ardpan ❑f{J� Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I-� T (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well„. -_-___Distance from f undation__-�Q_---------Ma#erial_ ____ _____ _____ g,______________. .No. of compartmenrs-----'7---------------Size___ Liquid depth_ _ _________Capacity__,�.`--�----- Disposal Field: Distance from nearest well,, Distance from foundation ___ �(, .........Distance to nearest-lot lin ______ Number of lines_____-__ ____ - � � -_-- _-- __ --- -- Length of each line_-- �- ----, ----.Width of trench-----�------------------------- Type of filter mate r, !-- Depth of. filter material---1_ __ ___._Total length_ __ ______________________ Seepag Pit: Distance to neares well_/Vd______--__Distance f m au ation____ �______.pistance to nearest Io ne_ D Number of pifs____ _______Lining material_ Size: Diameter____—?_-------------Depth------ __________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-___--__:_____-________-___-----_-. p =-------- qCapacity----------------------------gals. Size: Diameter----------�---------------------------De th_____________--------------------- -------_Li Liquid -ell_ - riv Distance from nearest w _________ _--- Distant rom nearest bui Ing ----------------------------------------- P ❑ Distance to nearest lot line---------------------------------------------- = Remodeling and/or repairing (describe):_ ------------------ ------------------------------------------- --------------------------------------------•------------------- -- -------------- --------------------------------------------------•--•--------------------------------- --------------------------------------------------------------------------------------------------------- I hereby certify that 1 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 Joaqui Local Health District. (Signed) --------- ---ate-0-1 ^�- -------- (Ow ran or Contractor) 70P By:--- ----------�--- - ----- -- ------------------------------------------------------------------------------(Title)--- ---- ----------• (Plot plan, showing sae 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- ----�Lp-r'. REVIEWED BY DATE _ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE ------------------------- Alt rati s and/or repornmenclafions------------------------------- -----------„--=--------- - -- - _ or g---------------� .- -A "-------------- � f '} .- FINAL INSPECTION BY: V4✓----------------------------------------------- Date-----_! v ------------------------•-------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ' 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9---2M 9-51 Revised W-2100