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�F L APPLICATION FOR SANITATION PERMIT Permit No. ____- -- -- (Complete in Duplicate) Date Issued ___S _--_��'-Sr��y qpplication is hereby made to the San Joaquin Local Health District for a permit to construct and QnstalI the work herein described. ., This application is made in,com lia�c with County Ordinance No. 549. ate. ------ ------- -� ` ---------- --JOB ADDRESS A D LOC ATION__ - 1 � --- --------- - -- Owner's N r'he_�_____.___- --- ---------- =-��+'�-kms Phone--- Address--- ! :-1 ------ ---------------------------------------------- .... 1 Phone_---------:------------------------ Contractor's Name--- ` '1 "i - --------------- ------------------------------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ ` Number of living units!�__ Number of bedrooms Number of baths -___ Lot size ____-_____________________________________________________ I Water Supply: Public system ❑ Community system ❑ Private �pth to Water Table -------- ft. .rI Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy'Loam ❑ Clay Loam ❑ Clay ❑ Adobe[t. Hardpan ❑ Previous Application Made: Yes ❑ No �Z New Construction: Yes IR(No ❑ ' 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------------------�Maf'erial--- __-_________-__---.___-._---------'� ~ ❑ No. of compartments Size_ Liquid depth- --------- --------Capacity ------ --- ------- tf Disposal Field: Distance from riearest well________________.Distance from foundation_________ __ . Dista a to nearest lot line___.---------_. ; Number of lines-----------------=- 9 ` C t . ❑ ----------------Len Length of each line Wid of trench a.. Type of filter material---------------_---------Depth of filter material------------ ce onearest lot line_._._________ To al length----•---------------------------- ____Distance from foundation____-" _------------D istan F Seepage Pit: Distance to nearest well_____________ __ i . Number of its-----------•----------Lining material-----------------------Size: Diameter-----------------------.Depth-- �� P Ces�{s?ool: Distance from nearest well________________Distance from foundation------------------ Lining material.----------------------------...____A Q Size: Diameter---------------------- p ----------Li Liquid Capacity----------------- a �1" Depth q P tY g 75 __Distance from nearest building } : Distance from nearest well------------------ ------------------------- g -� ❑ Distance to nearest lot line-------------------- --------------------------------------- --� --- ----------------- ------------------ Remgd lig and/or repairing (describls): ��- - ~ - -------------- . v. I _ ---------- -----------------------------•----------------------------------- ------ ---------------------------------------------------------------------•--------- ---------------------------------------------------------------------------------------------------------------•------------------------ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couni _ ordinances, State la s, and rule?an regulations of the San Joaquin Local Health District. Si ned (Owner and/or Contracts --- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ADATE ------------------------------------------------ ATE ---------------------------------- ----- � APPLICATION ACCEPTED BY�--------------------------------------------------------------------- ------ ---------- 1-�-- REVIEWEDBY ------------------------------------------------------------------------ DATE --------------------------------------------- ---------------- ---- ----- ------------ DATE. PERMIT ISSUED--------- -�--- -- -- ------------- BUILDING Alterations and/or r o mendations:___,.'��--_� ---- --- --- - -- --- -- "/ " '"" ...... ----- - ----- ---- } _ _______________________________________________________________________________1_.____ --------------------_-------------------_____------------------------- S FINAL INSPECTION BY:------ -----------------------•------------------------------ Date 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 B-51 Revised W-2100 "