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f s APPLICATION FOR SANITATION PERMIT Permit No. _______ _______ (Complete in Duplicate) - �•,5`'ff11 Date Issued ---- -----• •------T Applicia ion 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 LOCAAT�ION.---n-`-�=5------�-'-4:2--�}'-�(`�---U-------------------�_'1�" Owner's Name ---- I-- - A , --GV�-- ------• �� 1 Phone Address "" -----••--------- 1V•-j�-------------------------------------------------------------•------------------------------ ----------------------------- Contractor's7Name__---�---------------• ------------------------ -- ---- -- ------------- - -----`----- ----------• ------ Phone------------•---------------------- - Installation will serve: Residence ❑ Apartment House.❑ Commercial Trai[er Court' E] Motel ❑ Other ❑ Number of living units: __d-_ Number of bedrooms __Q_ Numbj ____ Lot size __________--- ---------------- Water Supply: Public,.sys#em Community system El Private E] Depth to ater Table ___-____ ft. Character of soil to a depth of�3 ,et: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes Eg"'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' t (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----•-•-k----------------------Liquid depth--------------------------Capacity----------------------- D;spcsal Field: Distance from nearest well-----------------Distance from foundation---------__--------Distance to nearest lot line________________- ❑ 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 well----------------------Distance.',from foundation._...................Distance to nearest lot line_-____-_________ rn E] Number of-pits----------------------- material____-_-----------------Size: Diameter-----------------------Depth_- ____ �+I Cessp 01; Distance from°nearest well-_�---- ---Distancel_fLom—fou.ndation.--a' _-.Lining--materialY� `" ?" i. - . - - ;- Size:-Diameter---- _CC.I______ _.____Depth---------•-�� .7rte------ - Liquid Capacity f gals. Privy:' Distance from nearest well---__--------------------------------------------Distance from nearest building------------------------------------------ F-1 _____--____________________--__________- ❑ •-- Distance to nearest lot line----------------------------------------------------------------------- Remodeling and/or repairing (describe):-____-Wz ' " t�-- -^� _ , ----------, == J44 A -------------------------------------• -•---------------------------- -------•------------------------------------------•------ , ' I hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) I U ---{Owner and/or Contractor) By:.-_ - --------- --------------------------------------------- - Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------=--------- ------------------- ------- ------------------------•---•----------- DATE '" REVIEWED BY----- ----------------=---------------------- --------- - -------------------------------------------------------------------- DATE-------- ----• ------ - BUILDINGPERMIT ISSUED-------------- -==---------------------------------------------------------------•-------------------- DATE----- -•----------------------------------------------------- Alterationsand/or recommendations---- = --------------------------------------- ------------------------•-•---------------------•-------------••-•-------------------•---------------------•--- --•-----------------------•-•-----------------------•-••----- t --------------------------------------------------------------1. --•---------•----•---------------------------- ------•--•-----------------•_ ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------•--- ---•----------------------- ------------------------ -- --------- ----:----•---•-------------------------------------------------------------------- C -----------------------------------------------------I- _-'---------. FINAL INSPECTION BY:.--- ter.. -•----- Date.- .------- ~- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M Revised W-2100