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_ t 7�j ,( f� APPLICATION FOR SANITATION PERMIT Permit No. ___. 11(1-. ..�- (Complete in Duplicate) Date Issued 41-1 - ------_-••-- r o s�-o9 Appli�ca}ion is hereby made to the San Joaquin Local Health District for a permit to construct and insta I the work herei described. This application is made in compliance with aunty Ordinance No. 549. s JOB ADDRESS AND LQQATIO --- _ I ---- Phone - ---- ----- Owner's Name------------- ----- ------------ I - - • ------ Phone----------------------------------------------- ne----------------------- - Contractor`s Name-------------------- -- •-------•-------------------- Installation will serve: FRes,idence � partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.-)-- Number of bedrooms --le-Number of bathsLot size ------- --- ---- --------------- Water Supply: Public system ❑ Community system ❑ Private,& Depth to Water Table ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam" Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ElNo X New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi l Tank: Distance from nearest well-----------------Distance from foundation--------------------Material________________________________________________ EP . w No. of compartments---------- •----------- Size---------------------------------Liquid depth-- Capacity 0 Disposal Field: Distance from nearest weU-----------------.Distance from foundation--------------------Distance to nearest lot line----------------- i Number o7 lines----------------------------------Length of each line------------------------------Width of trench------------------------------------ Total ------------------------ ------ .1Z Type of filter material--------------a-/-----Depth of filter material-------------- length-------•_------------------_-- --.--•f-- Seepage Pit: Distance to nearest well-_-�Q.__-_ Distance fr foun tion___ __-__..Dista ce to nearest loth ine -- Number of pits---------(-----------Lining material _-- Size: Diameter-`��-- -----------Depth_._��.._ ______ -+----- i � � Cesspool: Distance from nearest well from foundation__________________.lining material_---________________-_---_________ __ Size: Diameter----------- --------------- ---------.Depth------------------ - `----Liquid Capacity----------------------- gals. ❑. Distance from nearest building i Priv Distance from nearest well------------------- ----- g ❑1 _ Distance to nearest lot line-------------------- ---------------------------------------------------------------------------------- 1y - - --------------- 'fes Remodeling a /ar rep �(d - ---- r t - ---------------------------------------------- ------- ------ -------•---_------;----------- ---------------•------•-------------------------------•------�----•---------•----------------- -- -----------I----------------------------t---------------------------------------------------------------------•------------------------•------------------------------------------------------------------- I h#- hereby certify that 1-have prepared this application and +ha+ the work will be done in accordance with'San Joaquin County b ordinances, State laws, cind rul nd regulations of the San Joaquin Local Health District. (Signed)---------------- �/ - ___(Owner and/or Contractor] I -----k --------------- -------------- -------------- --------------- - --------------------------------- Title (Plot plan, showing size of lot, location of system in rela+ion to wells, buildings, etc., can be placed on reverse side). , s FOR DEPARTMENT USE ONLY "r ` DATE-----------•--` APPLICATION ACCEPTED BY------ ------- ------------------------------------------•---------------- -- '� _ _� REVIEWED BY---•---------'-------- ----- ----------------------- DATE----- ---- --- BUILDINGPERMIT ISSUED------------•--------------------------- --- ----------- DATE --'-•----------------•-----------=-------- Alterations and/or recommendations-------------------- ---------------------------- -------- -- - -------- ------- . ' .. ------- ---------------------------------------------- - --------------------- ------ --------------- --- ------------------------------------------------------ ---)--------d--------- � f ss FINAL INSPECTION BY::._- - " : Date--- -----------F-- ------ ------ 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 f, FS-9-2M Revised W-2100