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Permit No. _ - ----- APPLICATION .FOR SANITATION PERMIT 2 11 � (Complete in Duplicate) Date issued Application is hereby made to the San .loaquin Local Health District for a permit to construct and instO the work herein described. This application is made in compliance;with County Ordinance No. 549. . ---� ---- --r---- --------------- 10B ADDRESS AND LOCATION Phone ---- --------------------------------- Owner's ------ ------------------- ---------- -- - --- -- -- - Owner s Name----------------- - -- -- --- . Address--------------------------------------------------=------------------------------------------------------------------------- -------------------------- Contractor's Phone Contractor's Name------------------ -- ---- -- ----- - -- -- - Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: ___ _--- Number of bedrooms ____-_ Number of baths --t_ Lot size ------------- --------- -- -------- _ ----- Water Supply: Public system Community system ❑ Private 1-71 Depth to Water Table ft. e Character of soil to depth of 3 feet: S d-E] Gravel ❑ Sandy Loamn Clay Loam El Clay ElAdobe❑ Hardpan ❑ S Previous Application Made: Yes No ❑' New Construction: Yes [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel4______________ __ ,istance from foundation_ ______-____Materia!_______- No. of compartments_ ---------Size--- ° ` + Liquid depth Capacity El Field: Distance from nearest well------------------Distance from foundation________--_____-----Distance to nearest lot line___-_-�_____-- isp ❑ Number of lines---------------------- ------------Length of each line -Width of trent Type of filter material-------------------------Depth of filter material-----------------------Total length----------------------------------------------- ------------ S ___------------------------------------- [ Distance to nearest lot line_________________ V� Seepage Pit: Distance to nearest well----------------------Distance from foundation----•------------- __-___-___Depth-- -_____-line ----- ----- ❑ pits`- -----------------Linin material_____--___------------Size: DiameterruiQ --____-- ;Stance from founclation _- Lning material___ ----- -___ ________ _______• C spool: D stanceofromnearest well _ - uid Ca acit Size: Diameter---- -' •-- ---------Depth_---- p Y ---___-=Distance from nearest building------------------------------------------ Distance ---------- ----------------- -- _v �....,w . t -"- LDistance to nearest lof line---- x Y Distance from nearest well-------------------------------- Privy �, _ - ---- - - - --- -------------- --- --------- Remodeling and/or repairing (describe):-------- ------------ -- --------------- ---••---------------- --------------------------------------------- ------------------------------ ------------------------------------------- - ---- ----�------------------ ---- s I hereby certify that 1 have prepared this application and t at the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re uI tions of the San Joa uin Local Health District. r ------------------- ------- [ wrier an r Contractor] -_p and/o (Signed)_ ----------------- - ------- ---------------------------------------------------[TitIe) [Plot plan. showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side]. .r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE---------------- 77-=---- _'~"� .� DATE ------- -------- REVIEWED BY---------------------------------------------------------------------------------- ------- DATE----------- ----- - - ------ --- ----- ---------- ----------------------------- ------------ BUILDING PERMIT ISSUED = •�. ----------- -------- •-------------------------------- Alterations and/or recommend tions_________________ -------------------- �. ---------------- - t .w --------- --------------------------------------- ---------- ---------------------------------- ----------- --------------- -_. FINAL INSPECTION BY..--------- ----- -- =--------------------------- �. SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 13o South American Street 300 California Stockton,r California Lodi, California Manteca, California Y� a ES-9-2M 8-51 Revised W-2100