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Z APPLICATION FOR SANITATION PERMIT Permit No. __�T ----------- s (Complete in Duplicate) Date Issued 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 Ord' an o. 549. -___-,-E - ---------------------------------- ------------- __ _______________________.-_______----_____ JOB ADDRESS-AND ATION ___ -___Owner's Name-------- Address ------ Phane. Address------------- ------ ----------------- ------------=--- �- --------••------------------- Contractor's- Name k� = Phone - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other �] Number of living units:.__ Number of bedroom--. Number of bath.-_ Lot size _ ------ x --_ ----------• �. Water Supply: Public system ❑ Commun'ity system ❑ Private .Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ . Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay El Adobe lardpan ❑ Previous Application Made: Yes ❑ No P-'**`New Construction:'Yes E! No �HA/VA: Yes ❑ No �^ TYPE;OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) S }Tank: Distance from nearest well--------------- Distance from foundation--------------------Material------------------------------------------------- No. of compartments ----------------Size----------------------- ---Liquid depth------------------------Capacity---------------------- DisField: Distance from nearest wellDistance from foundation______---_______-_Distance tanearest lot line__.____.__----._. r Number of lines------------------- Length of each line-----------------------------.Width of trench�-------- ----------------- --------------- Type of filter material ------------------Depth of filter material-----------------_!_-Total length____.-.._- .... :----------- Seepage Pit: Distance to nearest�'�i -_-_ _Nstance §tom fou ation____ -__._..Distan e,to nearest lot iine___:_9--_____ Number of pits.___-/-___._--____Lining materiaV-� Size: Diameter--/ ---_.Depth- ------------------- Cesspool.: Distance from nearest well________- ----_Distance from foundation--------------------Lining material--------------------------------------- O Size: Diameter------------------ - ----------------Depth---------------------------------------------------Liquid Capacity------------- ------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------- -----. r,= ❑ Distance to'nearest lot line_____- Remodeling and/or repairing (describe) �� --- - ' V ------------------------ ----------------------------- ------------------------------------------------------------------------------ 'E ________________________________________ ________________________________________________-______-______-________________-______--__._______.-_____-________._-__________--____________________________________________________ 1 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 reg tions of,#ie San Joaquin ocal Health District. ,� - = [.cam"- -----------------------------(Owner and/or Contractor) (Signed)---------: - 13y:. - �----------------------------(Title)--- ►� (Plot plan, showing size of to+, to n of system in relation to wells, buildings, etc., can be placed on revers ode). } F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- - -- ------ ------------------------------------- DATE REVIEWEDBY------------------------------------- - ---- - . ---- - --•----------------------------------------------------------- DATE ---------------------------------- BUILDINGPERMIT ISSUED------------------ -- -- -- - ------------------------------------------------------------ DATE-- --•---------------------------------- i Alterations and/or recommendations:------ - ----------------------------------------- ---------------------------- -------------.----------------------- --.: 1 ------- ---------- ------------ -------------------------------- -- ----------------------------- ---------- _ FINAL INSPECTION BY_ --- -- Date---- ~r.--- ---------- --- =.------f---------- SAN JOAQU LOCAL HEALTH DISTRICT 130 South American Street t 300 West Oak Street 132 Sycamore Street 814 North "C'•' Street _ Stock}en, California Lodi, California Manteca, California Tracy, California T sF ES-9-2M Revises 1-57 F.P CD. k -