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V ' � '�`3 APPLICATION FOR L �( SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued �_6 ericafi,on is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described.pplication is made in compliance with County Ordinance Vo. 547,L JOB ADDRESS A OCATfON__._____ --------------------------------------- ----------------------I Owner's Name :. _. _ ------ 1------------------------------------------------------------------- Phone---------------------------- �j ----- - Address------- -•�------- .� ----------- -- -,..�./ -- -------------------------------------- ontractor's Name____ ----------------------------------- ---------- ----------------------------------------- ------ Phone----------------•----- Installation will serve: Residence t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel) ' /� ------------------ El Other i Number of living units: :_-_ umber of bedrooms ____ Number.of baths _"'_ Lot size ___�/-1,I- ' . Wafer Supply: Public system )Community system '❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand , Gravel ❑ Sandy Loam [3 ClayLoam Clay❑ y ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes �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_________________ ..Material ---------------------------------------- ❑ No. of compartments Size --------Liquid depth---------------- -------- Capacity------ ----•---------- Disposal Field: Distance from nearest well_-----__-__---Distance from foundation-------_------------Distance to nearest lot line... - ._. ❑ T Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------•----- ------ YPe of filter material------------ ----Depth of filter material-----------------------Total-, length------------------------------ ----------- Seepage Pit: Distance-to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____.___.______ xPWI Number of pits------------------ fining terial-----------------------Size: Diampter:_o--_ ____ __nn - --- -Dep ---- --- ------------- ---- CesDistance from est w I1_.. ______Distance fr �{/`'�Yt IFoundation__-- - ----- Lining material--------- -------- --------------- Size: Diamete , --Depth- --� ----------- --- -- --- -- Li uid,Ca acit _ �" Priv . " --------- 'TZ fax Y � Distance from nearest well- _...____ Distance from nearest building__ '. ;emod in and/or r ainng (describe)=------------------------ ---------------------------•-•--------------------------- =--------- - -- -- - -I - - U- ---- d that the work will be done in accordance with San Joaquin County ! hereby certify that I have prepared this application an ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- Sy''---- r___- ----------------------------------------------------- ------- - --------------- ( �� - ----- --'-- --��. r Owner and/or Contractor) --- ------------------- -----------------(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 APPLICATION ACCEPTED BY__ ----------- DATE . REVIEWED BY - �- ------"---------------------- ... .....-7-.-.-.. ..-----------------------------------------------.------------------ DATE--6 BUILDING PERMIT ISSUFD ----- -------------------------=------------------------------ ------------ DATE.- . Alterations and/or-r--e-commendations------ . -- ------------------------------------------------------- --- ' FfNAL INSPECTION BY:-------.-.__- ----------------------------- ------ Date-. --------------------------------- k SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 5-51 Revised W-2100