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JAS r ,� 4,d,�r .- �� .' -� 1�_ _ •� '?..ir,:�' k_ r _ APPLICATION FOR SANITATION PERMIT Permit No. ___ • (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Loca Health District for a permit to construct and install the work herein described. This application is made in co r�ipliance with'County Ordinance No. 549. JOB ADDRESS AN LOCATION.---Z.-- --------- - -- ------ -- - - Owner's Name---;. ------ -----• ----- --------• 1---- ------- ----- ---------------------------- ------------------ -------------------- Phone --------- I { Address -•--------------------------- ----------------•------------------------------------------------------------------------------------------------------- t Contractor's Name ------ --------- ------------ ------------------ --- ---------------------------------------------- ----- Phone----•----------------------`------- Installation will serve: ''Residence Apartment House ❑ Commercial ❑ Trailer Court [ ' Motel ❑ Other ❑ J; . Number of living units: -1--__ N; umber of bedrooms ________ Number of baths ____--- Lot size ______________________________________________________-__-_ ~Water Supply: Public system F1Community system '❑ Private E] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Se tic (No septic taD�stancecesspool rom pea alit weft publicistaner is available within 200 feet.) I la ce from foundation----=---------------Mate'rial------------------------------------------------- No. of compartments--------------- Size Liquid depth--------------------------Capacity-----------------t Dis osal �Fi Distance from nearest 6_1 _-Distance from foundation__ -- _ ___Distance to nearest I9� li ..pNumber of lines---------- --- -- --- '--Length of each line------- __r_tf Width of trench------fit__ ------_------- Oq i Type of filter maters -Depth of filter material- -6------_Total length-------- Seepage ___---� _______ See a e Pit: Distance to nearest well____ _______________Distance from foundation---.__-__-----------Distance to nearest lot line_______________-. .f P 9 ❑ Number of s Lining material � atematerial t�fmfounaCe _ W- on Lining _____fromneZe Size:,,Diameter - -------------------- ------Liquid Capacity.----------- ------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----_-----------------._____-_----------. i ❑ Distance to nearest lot line-------------------------- ------ ---------------------------------- ----------------------------------------------------------------------- Rem rin nd/ r repa ring (de ribe):-------- = ------ = -c-- F ---- --- ' -------------------------------------------//-------------------------------`-------------------------- ---------- -1 --4 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 ofjt}ie San Joaquin Local Health District. '(Signed)_t_ ------------------ ------- __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 F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------------- ---------------------------------------------------- DATE",_ REVIEWEDBY------------- - - - ------ ------------------------------------ -------------- ------ DATE--- -- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.-------- Iterationsand/or recommendations------------------- ---- ------------------------------------------------------------=----------------------- --------------------------------------------- -- ------------------------------------- ------------------ ------- ----------------------------------------------------------------------------------------------"------- -------------------------------------------- --------------------------------------------------------------------------------------=-------- ---------------------------------------------------------- ----------------------- ----- ---- ---------------------------- ------------------------------------------------------------------- ------------------------------------------ ----------------------------------------------- ----- -- FINAL INSPECTION BY:----- -- - �----�- ---- �� --- 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 ES-9-2M B-51 Revised W-2100