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11 APPLICATION FOR SANITATION PERMIT Permit No. .___� '_ ..Z in Duplicate) (Complete p. Date IssuedY:'_�l-_hl! Applica+ion is hereby made:to the San Joaquin Local Health District for a permit to construct and install a work herein described. This application is.made.in compliance wi County Ordinance No. 549. SCS - p Ci W:jz _✓�J._Lu.c ,fir JOB ADDRESS AND C 10 ------ --- -------------- -- -- -- -- --- Owner's Name---- r --------------- _ Pho , Address--------.... ( _ �, -- "-"---------f--------------- -.---------- Address F Contractor's Name -----------=----- Phone. --- �- - . Installation will serve: Residence Apartment ous Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ s.�__ Number of baths ,�____ Lot sizeT1_. �1 Number of living units: ___�__ Number of bedroom --��---------- --~------------- Water Supply: Public system ❑ Community system ❑ Privat Depth to Water Tableft. r am" Character of soil to a depth of 3 feet: dSand ❑ Grave! ❑ Sandy Loarn Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No TYPE OF INSTALLATION 'AND SPECIFICATIONS: i(No septic tank or cesspool permitted if public s9wer is available within 200 feet.) ' Septic Tank: Distance from nearest we11�/------Distancefrom f udaion_/&___-___._____".Mat9ria_:__ -__________ ___ �---Li Liquid de th_ _ _ -Ca Capacity__ -No. of compartments--Z---=------------Size_ 10. � Y lDistance to nearest lot hne___ Dl FieldDistance from nearest well�d _Distance from foundation_ _ 1 kNumber of lines_._______________________ _____Length of each line____ -----.Width of trench_.. Type of filter materialZ� -------Depth of filter material___ '--"""--Total length__-..__-_�_�� 1 ..,, ,.. Seepage Pit: Distance to nearest well----------------------Distance from foundation.".----------------Distance to nearest lot line_____; 1rjF 171. Number of pits----------------------Lining mi Daterial.----------------------Size: Diameter--------•-------------- epth--------------------------------- � f p Gesspool: Distance from nearest weil_____ _____ µ - Lining._ "_Distance from foundation______ :__;".Lining material_____________"_____.________-_______. N ❑ Size: Diameter--- -- -------- ----------------Depth------------------------------------------- ------- Liquid Capacity gals. Distance from-nearest well_----------- ----, --_------------------------------------ --Distance from nearest building- 1 , • '❑ Distance to nearest lot line--------------- ------------- - -------------------------------------------------------- , Remodeling and/or repairing (describe) �i',.Fv<!� t �--•-------------------------------------------•--------------- 1. ----------------- - --------------•------------------------------------------- -------- ---------------------•------------------- -of I ---------•----------------•--------------•---•------ ------------------------------------;------------------....._-----"------------------- ------ -------- I . i f - ------------------ --------- -----••-------•------------•------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta a'ws„and ules and regulations of the San Joaquin Local Health District. r E s wn and ontractor] (Signed)- i i er BY� -- ---- --------------------------------------------------- ------------------------(Titl - - �''------- - ------ (Plot plan, showing size of; , location of system in relation to wells, buildings, etc., can be p a on reverse side). 4 AOR DEPARTMENT USE ONLY x APPLICATIONACCEPTED BY------------- ----- --------------------------------- ---k-------------•----------- ---- DATE------------ � - REVIEWEDBY--------------------------------------------------------------------------------- --------- DATE----------- -----------••-_--_----- --------------- BUILDINGPERMIT ISSUED------------------------------------------------- ---------------------------------- DATE ' ' Alterations and/or recommendations: --- --------------------------------------------------- - � ------••------------------...-------------------•----------------•• -------- -------------•-------------------•--------------------•-----------------------------------------------------I-------- ---------------------------------------I-------------------------------------------------------------- --------- ----••------ ------ -------------------- ----------•---------- ----------- � • ------------------------ -----------------------------•--------------- -�-•------------•--------- -------------------------------------------- - = -------------L---- ----- -------------------- ......------ B � - r m: FINAL 'INSPECTION BY:.. -- ""-- ---------------------------- -- ------------------ -+ Date....... -----------------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M ; -Revised W-2100