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I ! PPLICATION FOR SANITATION PERMIT Permit No. ..:;�., _1/.... (Complete in Duplicate) n '/ Date Issued Application 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 rdi ante No. 544, t ®� JOB ADDRESS AND LOCAT ON_._, __j U___.._ _-_ ------- Owner's Name -------- --------- Phone_.. /�,�� Q - ---- Address--- -1-----r•s�rr �� 7--1------------ --- Contractor's Name...............................................------------------------------ ------- . _ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Comme ial Trailer. Cou tMotto A�fler Number of living units: ______._ Number of bedrooms -_O-. Number of baths _f_ ___________ ------ ----------- Water Supply: Public system E] Community system C] PrivateA Depth to Water Table ._—. ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobey//�q� �rHJa//�rdp n ❑ Previous Application Made: Yes ❑ No W New Constructs n: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: U (No septic fink or cesspool permitted if public sewer is available within 200 feet.) _ Septic an ce from nearest well-----------------Distance from foundation--------------------Material_____________-___________.______.__------_----- - No of compartments--------------- ----------Size_--_-------•----------- ---Liquid depth-------------- Capacity------------------- I Dispo al Field: Dis ante from nearest well------------------Distance from foundation_------ -------- Distance to nearest lot line_______-_.__-_ Q Number of lines----'.---------------------------Length of each line------------------------------Width of trench-.--------------------------------- �/�fi� Type of filter material_________________________Depth of filter material_--.____.-_------------Total length___.____._____________________________) �S�epage Pit: Distance to nearest well__--------------------Distance from foundation----.---------..___.Distance to nearest lot line------._____C ❑ R er of pits......f---------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------- - --- 1 I Cesspo Di nce from nearest well____ --_ -_Distance from fou dation---___6------Lining material-__.---_._ _____. 1 - -_ - Size, .Di afar. ?� i<a` -._.Depth –_�= = '=-:�LiquidCapacity ' = Q-C gal i� stance from nearest v✓eIL_______________._.___________________ Distance from nearest building----------------------.___-___-_..._-._ Gds'❑ Distance to nearest lot line ---------------r------------- XT ---= ------- model' g a d/or epairin describe :-a---uot 1 . -------------r`` --- ------ G' - - ----- - - ---- *`'4 -� -�---------•------------------------- --1-----• ----------- ----------------------- ----------- -------------------- ---- ----- ---- 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la and rules and regulations of the San Joa 'n ocal Health District. Owner and/or Contractor (Signed)-------------------- ---- --4�1------- -- - - - - - - ----------------------- --------------------------------( / ) By-—---------•---------•- • --•-•----•------ ------------------------------------- --------------------------- - -----------(Title)--------------------------------------------- --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, tc., can be placed on reverse side). FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY-------------'.--------_-- _ -- -__ _ _ -- DATE-------- - - ------------_ . _ REVIEWED BY ------------------------ DATE----- -��- ©--�--------- BUILDINGPERMIT ISSUED..---------------------------------------------------------------------------------------------------- DATE------ ------------------------------------------------------ Alterations and/or recommendations------------------------------------------------------------------------------------------------------------•---------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------•--•------------------------------------------------------------------------------------ .t, --------- ----- o --------••--------------------•-------•----------------•-- --.....-..------- --'--- -- -----..__.....----------------------------------------------------------------------------•-------------------------._.---__-G.- FINAL INSPECTION BY------------ -•--------- -------- dam---------- Date------- ----------- - ------ -- ------•--------- ----------------------------- . 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 K, ES-9--2M 0-52 Revised W-2100 ��. 1