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APPLICATION FOR SANITATION PERMIT 'Permit No. 11-l __ ,,._ (Complete in Duplicate) y�/� ��,�" . '1 a Date Issued Application is hereby made to the San Joaquin Local Health District for a permitltoo construlct and install the work herein/described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCATfONL•� y .. ' ti -- = --- _ --------------------------------------- Owner's Name--------------- ------1. _ ( -------------------------------------- Phone" Address -------------- + ------------ Contractor's Name-----------------------------I---- - • -•--•----- ---------- Installation will serve:! Residence ❑i Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms-------- Number of baths -------- Lot size Water Supply: Public system [] Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe-❑ Hardpan ❑ Previous Application Made: Yes ❑ I No ❑ New Construction. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well-----------------Distance from foundation________________ Material F1 No. of compartmi nts-- -----------------------Size.------•------------------------Liquid depth----------------- Capacity Disposal Field: Distance from nearest well------------------Distance from foundation------------------ZDistance to nearest lot line--- -_._ - _ --- . ❑ Number of lines-_i____._____._._----"_______._.-_Length of each line------------- Width of trench "--------------" _ Type of filter material_ ___"________________Depth of filter material-------------_---------Total length-__._____--___ Seepage Pit: Distance to nearest well-----_-----------------Distance from foundation_______--______._.-.Distance to nearest lot line--------------- ❑ Number of pits.- I-----------------Lining material-----------------------Size: Diameter--------------- --------Depth------ -------- , Cesspool: Distance from nea rest well _._""_______.---Distance from foundation___----------------.Lining material---_ ------ Size. Diameter._-J Depth __"________________------------ I --Li uid Ca Capacity ------------------------gals. A Privy:( Distance from nearest well---------______"_Va_". -----------'Distance from nearest building �►`` LSa Distance to nearest tot linelf?_____________________-__ ------------- Remodeling and/or repairing (describ"e):_-___-_____-.__-_____---__ ------------------------------------------------------------------- ------------•-----------------•---•--- ------------------------------- -----------•-•--- -------------------------- - ----------------------------------------------------------------------------------------- -------------------------------------•------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Y, aedrules and -regulations of the San Joaquin Local Health District. (Signed)------- a- �--�-�_/ °C.1 --- (Owner and/or Contractor) By: ----- Title _________ _ o+ plan, showing size of lot, location'.of system in relation to wells, buildings, etc., can be placed on reverse side). — --e 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ -��!- - - ------- ----------• ---------------- DATE------------ REVIEWED BY .. �------- mss~-'•--->3----------------- ----------•----------------------------------------------------------------- DATE BUILDING PERMIT ISSUED-------------------=--------- ------------ ---------------------------------------------------------- DATE.--------------------------- -- - Alterations and/or recommendations--"!_______________ --------- --------------------------- ----------------------•- ----- ------------------------------------------------------------ f ---- -------------------------------------------------------------------- __ _______________________________________".-___--______-_-_------- FINAL INSPECTION BY------------------ ------------ --------------- ---------- Date---- -------------- ---------- € SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M t0-52 Revised W-2100