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y APPLICATION FOR SANITATION PERMIT Permit No. -__''�7. (Complete in Duplicate) Date Issued Applica{ion 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 Ordin;ne,No. 549. _:_ -- � -- --------- Owner's ADDRESS ANp LOCATIONs'_ -- _ -- --------------•--------____-- Owner's �- --------------------- -------------------------------------------- Phone------------------------------------ Li � :_ -------------------------------------------------------------- Address ----------; { Contractor's Name - ------------------------------- ---------------..__.._. Phone----------------------------------- Installation will serve: Residencet Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _--/__ umber of bedrooms --0_. Number of baths _1___- Lot size __. ____ 1 -------------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe 0"-`Hardpan ❑ Previous Application Made: Yes ❑ No ®� New Construction: Yes [ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sews er)is available within 200 feeti f . p l�0-'y__•_�_-Distancie from fo nation_/_1�-- Materiol------------t� __ Se tic lank: Distance from nearest wel- No. of compartments------... -" •--Size _ Liquid d�e�pt�h,--- --414.-------------Capacity...Y _-- Dispos Field: Distance from nearest welr519~ Disfance from foundation_119_-L►i`' .Distance to nearest lot ling__, ----- 14 ',Number of lines__________ _. : _____ .Length of each line-------------- _e+-_*-------Width of trench_______I(t _t________-__ y ggI1 Type of filter materi _-. _' __ Depth of filter material------@_,O-_----.--_Total length-----------�-_,�/__o________________ p � Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_------._--._____ N [] Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_._______.______-.___-____________. ❑ Size: Diameter----------------------------- ------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building__.________________---_-____________-__ ❑ Distance to nearest lot line------------------------- ------------------ - ----------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)--------------------------------------------------------------------------------------------------------------------------------•------------------------ ------------------------------------------------------------------------------------............---------------------------------------------------------------------------------------------------------•--•------------ --------------------------- -•----------------------------------------------------------------------------------------------------• •- --------•--•-------- ------------------------------------ I 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 of the San Joaquin Local Health District. Si ned �� 1- --- .,...__!': <;*`--C- ------(Owner and/or Contractor) Sy=---•----•-------- -----------------------------------------------------------------------------------•---•-----------------------(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.- REVIEWEDBY------------------- _ 1�, -------,---,----------- --------------------------- -------.-------------- ---• DATE*. BUILDING PERMIT ISSUED---- - 1-----------------r--------------------------------------------------- RATE .. Alterations and/or recommendations----------------=- --------------------------- ------------------------------ ..----- � �--------------•----•----------------------- ----------------------------------------- ---------------------------- �A'a_tti/ p�� r----... -----------------------------------------------------•---------- ------------------ -----------------------------------------------------------------•------- -4Atj... ... ----------- r. `f-- ----�°-------` ` Rw--`---'----- $ I------pe-7- ----------------- FINAL INSPECTION BY:.------- -- /! '----------------- Date-- ----------- - ----------- ------------------------------------- SAN -------- ---------------------------- 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 Revised W-2100