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APPLICATION FOR SANITATION PERMIT Permit No. _Z5_-0-__f�_____/ } (Complete in Duplicate) 9 S Date Issued I 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. This application.is made in compliance,with ounty Ordin nce 'No. 549. 4 f JOBADDRESS DLO ATI > _: ------------------------------------ '' -----------------------------------------------------------------------------[' Owner's Name --- ------------� .. ----------------------------------------------------------------------------------------------------- Contractor's Name- ----------------------•- -------------------------------------------------------------------------------- Phone--------------------------- Installation ---- ----- ------------------- Installation will serve: Residence ;Apartment House ❑ Commercial El Trailer Court E] Motel s❑ Other E] Number of living units: ___�-_- umber of bedrooms --- Number of baths ---I-_ Lot size tOG7_0----------------- Water Supply: Public system [Community system '❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy LoClay Loam E] Clay ❑ Adobe Hardpan F] ! Previous Application Made: Yes F-1No I] New-Construction: Yes ;"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: `` l (No septic tank or cesspool permitted if__p�ubpc sewer is available within 200 feet.)f ?J Septic a�nk: Distance from nearest weIf5P__*_-Dista cp fr tfo ption__,9-----------Mate i�L_____ __________________ ___ . -i--------. No. of compartments_______ F-._____Size _.}-_ ----Liquid d �Fh_________tT____'_______CapacitY___G�__ .__ ____ Disposal Field: Distance from nearest well __._.Distance from foundation-��_I___-i_.Distance to nearest I�lif ______. _ L�-' Number of lines_________ .__ _______ _ Length of each line__ _----_ Width of trench_______ _____ ------------ Type of filter materiDepth of filter matenal______�_ __{_____-Total length____-____�_ ______.___-___.____ " Seepage Pit: Distance to nearest well __-------------------Distance from foundation------------------- Distance to nearest lot line-------------- -. /►� ❑ Number of pits----------------------Lining material-----------------------.Size: Diameter-----------------------Depth--------------------------------- V Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------.----__.______ ❑ Size: Diameter--- ---------------------------------Depth--------------------- -----------------------------Liquid Capacity---------------------------gals. (� Privy- Distance from nearest well-------------------------------------------------Distance-from nearest building_______________--___________.__---------- V" ❑ Distance to nearest lot line-------------------------------------- ---------------------------------------------------------------------------------------- ------------- Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------- i ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ c ------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State ws, and rules and regulati ns of the San Joaquin Local Health District. (Signed) �1 y�� ..'--------------------------------------------------------------------------(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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- "--" DATE ------------------------------- r - -------------------------------- REVIEWED BY----------------------- �' -- --- -----._-------:----------------------------------------------------------------. DATE---- �- - BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ DATE------------- Alterat'ons and/or.recommendations:-------------=------'------------------------------------------------------------------------------------------------------ -------------------------------- ---------------------- -'--------- ---- - . "- ,-@----------------------------------------------------------------------------------------------------- = ! ------- ------------- ---- --------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---------1 ' '-------------------------- Date----- ' l�` ��---------------------------••--------------- L.�' r I F SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ! 300 West Oak Street 132 Sycamore Street 814 north "C" Street I Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 s