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h1_n , APPLICATION FOR SANITATION PERMIT Permit No. APPLICATION`' (Complete in Duplicate) _ .d. I Date Issue �s.. Application is hereby made to the SantJoaquin Local Health District for a permit to construct and install the work herein described. This application is made in complionce.with County Ordinance No. 549 JOB ADDRESS AND LOCATIO V X-10 ----------------------------------- Owner's Name__. ` ----- ---------------------------------------- Phone------------------------------------ Z -------- -- Address------ � ----w---- -¢------ ------• ------------- ------------------------------------------------------------------------ Contractor's Name----- '` - = Phone : Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I •— Number of living units: j--- Number of bedrooms j/---- Number of baths`- -- Lot size ---------•---------------------- Water Supply: Public system �o'mmunity system ❑ Private ❑ Depth to Water Tablet__--__- ft. F t Character of soil to a depth of 3 feet:? Sand E] Gravel E] S�Sly Loam ElClay Loam ❑ ,Clay ❑ Adobe Hardpan E] evious Application Made: Yes E] 'No 211- New ConstructionI: Yes ❑ No ❑ .. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer] a ailable within 200 feet.) 1 It A Septic Tank: kh� Distance from nearest well-------------_�Distance from foundation_--_--:-----:-.---.Material_.-._----------._----.__._____-----..---_---- ❑ �-4 No. of compartments-------------------- ---I-Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest weli------ --------_Distance from foundation--------------------Distance to nearest lot line---------------- Q ❑ Number oii lines----E---------------------------- -Length of each line------------------------------Width of trench-----------------:----------------- Type of filter material-----------------------1-Depth tof filter material length---.__...--------------------------- Seepage Pit: Distance to nearest well__ _ _,Distance __---- )1 from foun�ation__�_ _ --....___. istance to nearest lot line___/0------_. _ Q_ Number of pits..... --------------Lining material ".Wer-.Size: Diameter_4------------------Depth----- .1---____.____._.__-. Cesspool: Distance from nearest well-----------8_._Distance from foundation---.-- __----------Lining material.---____-_-_------------------------- ❑ Size: Dia Teter-------I------------------- ------- Depth---------------------------------------t------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------- --Distance from .nearest building_ ------------------•--------- --------- ❑ Distance to nearest lot line-------- ---------- ----------------------------------------------------------------------------------- it�. Remodeling and/or repairing (descr6e):--/4�D-- = - VJ.-.- 0,ev --------------- --------------------- --------------------- i --------------------------------- --- ! ` •---------------------------------------- = --- ------ •----- - --- ---- -- ----- - - -• - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance/Staff laws d rule andlregulations of the San Joaquin Local Health District. .W {Skgned) •• -------------------------------------------�;--------------------------------------{Owner and/or Contractor) BY ------------------••---- --------- ----•-------------------------------------------------- {Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings,'et6.a V be placed on reverse side). k ( FOR DEPARTMENT USE ONLY k --:---- DATE- APPLICATION ACCEPTED BY----------- ------ --------------- ---- ---- - ------------------ REVIEWED - -- ---- REVIEWEDBY--------------------- ---------- -----:- - ----- --- - --------------------------------------------- `-tJ------ DATE--- ----- - -= - -------- BUILDING PERMIT ISSUED------------- -' --------------------- ----------------------------•--------- ' DATE Alterationsand/or recommendations:`------ ------------------------------------------------------------------------•i---- -----•---..-.._-.-------------•••---•------------------------------ t -------------------------------•----------------------•--------•---•------- .. -----•--------• ••----•.--.- ...--•-•-------------.•- -------------------------------------------------- ------------------------------------ ----------------------- ------------------------------------------------------------------ l -------------------------------------------------- ---------------------------------- ------------------- --------- ----------------•--•--------------------------- I -- ----------------------------------------- Date ----------------------------------•_________-_ - I r FINAL INSPECTION BY:. , D te--i------ f -----------------------------------•--- SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 t ES-7-2M 10-52 Revised W-2100 r F k