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{ ;I r /� F r APPLICATION FOR SANITATION PERMIT Permit No�_�---L2-a-t w (Complete in Duplicate) Al r - Date Issued 3` __ '_a" I Application 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 Ordinance No. 549• JOB ADDRESS AND LOCATE ------- --------------- Owner's Name_____________________ -------------------------------------- -------------- ----------- Phone ----- Address------------------------/- ---- Address------------------------/- --- ------- , - --- --- -- ------------ ------ --------------------- - ---- ------ Contracfor's Name4 ----------------- Phone----- Installation will serve: Residence partment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ a Number of living units: __ -_.__ mber of bedrooms __ Number of baths _ _-_ Lot size __ _ --- _ ., ------------------- Water Supply: Public system Community system ❑ Private ❑„Depth to Wafer-Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam lay Loam E] Clay El Adobe ardpan E]Previous Application Made: Yes El N6 �w Constructir"_ Yes. V No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within kO feet.) r _ Septic Tank . Distance from nearest well- _ P Distance from foundation--------------------Material____-________.-_--__------ = No. of compartmerifs---------- ---Size-•------------------------------- Li uid de rth--------------------------Ca aci Dispo�aIA�9d: Distance from nearest welfoeyv4kDistance from foundation_y________y____-Distance to nearest lot nePOO ____-___T_-_____. Number of lines______ - �_ Length of each line :` } ; ____Width of trench____ r - ------------- Type of filter material__ /__ .--'--Depth of filter material_____f ____�.=____._Total Mength___ ___ p------.-_-_,------._ Seepage Distance to nearest well !_d FY- _Distance f m foun-afion_ Distance to nearest lot line_+ -_- - Number of pits----- s_ ing materia ��Size Diameter___________.____Depth___ ------------------ Cesspool:❑ DZetanDc frrom nearest well°_----------DDist+Ince from foundation-__,_______.. Lining material________________________________-__. , - ----,----Liquid Capacity---------- ----------------gals. Privy: Distance from nearest well____--_i----------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line------- ----------------- - --------------------------------- ----------------==:----------•----------------------- Remodeling and/or repairing (describe)!____ ------ -------------------------------------------------------------- ------------------------ -----------= I -----------------------------•----------- -------- -- . I - -----------------------------------------------------------------------------------'---------------------------------- --------=------------------ I hereby certify that I have prepared this app:licafion and that the work will be done in accordance with San Joaquin County ordinances, State la s, and rules and regulati ns of fhe San Voauin Local Health District, Si ned ( g ) _: �- �- ---------- ------ - ----- , ---------(Owner and/or Contractor) g!!, ------(Title)--- BY� ----- ----- ----- (Plot plan, showing size of lot, location of system ik',relation fo'wells, buildings, etc., can be placed oFi reverse de}. r _ FOR DEPARTMENT USE ONLY { APPLICATION ACCEPTED BY__________________ ---------------------------------------------- DATE----------- f ---- -=- -- - - ----- - -------- REVIEWED BY.-----------•----------- ---------------� ----- ------------------ --------------------------------------------- ; „""DATE------------------ ------------ - BUILDING PERMIT ISSUED ------- ----------- --------- ----------------------------------------- - -- - t - ---------------- --- --------------------- ---�--- DATE----�---------------- ---------------------------------------- Alterations and/or recommendations:___________________ L-._-� -►� --------------------------------------------------=--------- � ----- ----------------- ----------------------------- ------------ •---------------------------------- -- --------- rlNAL INSPECTION BY------=--------�/,/_ -_-- --v--------------------- Date--- -" J 2 - ' 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