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- - 7n , � -APPLICATION FOR SANITATION PERMIT Per nyt hW.---- `- -`- --�-------- M .01 \,�- i`�" (Complete in Duplicate) Date Issued A licaaion is hereby made to the San Joaquin Local Health District a permit to construct and install the work herein described. pP This application is made in compliance with County Ordinance o 49. r � - JOB ADDRESS AND LOCA - ---�----- _ _ Phone------------------------------------ Owner's --------•---------•-------- ---•---Owner s ame______________ � Address------------------------------------------------------------------- - Phone---------------------------------- �� -yy -------------------------------------------- Contractor's Name'----•----•---- ri --- ------�--------- - Installation will serve: Residence partment House ❑' Commercial ❑ Trailer Court El Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms _o . Number of baths __ ___ Lot size ___. U� -7.�---------------------------- Water Supply: Public system munity system El private ❑ Depth'to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted iff blit sew r is available within 200 feet.) I'��.� l - Material Septic Tank: Distance from nearest wel____ is ante rom foundation_ _ _ � Si e_ �7__Ligwd eptly--.�.xFi______- Capacity No. of compartments--_____ _ a Disposal Field: Distance from nearest well ��t s a ce �r"om foundation '--Disfance to nearest lot line____ Number of lines--------r------------- Length of each line--- - `-.,---Width of trench.--- r Type of filter materials - ,[tDepth of filter materiaL____�-� �Total length____...3-��-�I----a--•---------- Seepage Pit: Distance to nearest well______________________Distance from foundation_.-___.____.___.__..Distance-to-.nearest lot lint,________.________ ❑ Number of pits----------------------Lining material-----------------------. Size: Diameter---------------- -----.Depth----- ---z-.------------------ rom nearest well from foundation___________________ Lining material------------------------------------- Cesspool: Distance f - -- ------Liquid Capacity----------------------------gals. ElSze: Diameter------------ ----i =---= - Depth ------ - Distance from nearest building----------------------------------- ----- Privy: r Distance from nearest well---------: ----- -- ❑ 4 ? ------------- Distance to nearest lot line________________________________k t f Remodeling and/or repairing (describe):______..____._____ ' •t t ------------------ {f� c a -- �6 -------------- ---•----- ----------------------------------- --------------------- 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. I -----------------------------------------(Owne'r,and/or Contractor) (Signed) Title----------------------------- -- ------------------- Plot plan, sowing size of lot, loci+ion of system in relation to wells, buildings, etc., can be placed on reverse side. FOR DEPARTMENT USE ONLY .., s --------•- DATE------- rAWLICATION ACCEPTED BY -�^ ----------- `� ---------------------------------------------- DATE . --- REVIEWED BY---- - RATE.. ---- om- G P --------------------------------------------- n ---------------------- BUILDINERMIT ISSUED-------•------------ ----------------- Alterations and/or recommendations________________ ------- --------------- �...-•--------------- ---------------- r- ------------------- --- -----•---•---- ---------------- ---------- --------- , -- i -------- -----•------=--------•-------------------- ------------------------ FINAL INSPECTION BY.--- Date------.--- ~` SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S 814 North "C" Street camore Street 130 South America Street 300 West Oak Street y �,. Man+eta, California Tracy, California Stockton. California Lodi, California Fc�R-9M - Revised W-21Do