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Y u APPLICATION FOR SANITATION PERMIT Permit No. .__17'--,�03 (Complete.in Duplicate) p ,�. 1� Date Issued _ s qp i tion is hereby made to the San Joaquin Local Health District for a permit to constr ct and install the work herein describe'. This plication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----- --- ------- -----�---------- '---------------------------------- ----------------------------------- - Phone OwnersName--- ------------- e---•- -•-- --- ----• ------------------------------------ �----•-� ��-��---- ��, Addres � - --= = Contractor's Name r �.------- --------- ----------------------------------------------------- Phone _----------- r- P l Installation will serve: Residence Apar+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ / v ( Number of living units: _-_____ umber of bedrooms.- Number of baths _______ Lot size ________________________ Water Supply: Public system' Community system 'ElPrivate E] Depth to Water Table---_�___ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yeses No ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION ANDD SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200.feet.) i Septic Tank: Distance from nearest well_________________Distance from foundation-------------------.Material_______------_--_____..____________________-__.. No. of compartments--------------------------Size--------------------------------Liquid Di'sp❑asal Fi o ('f depth--------------------------Capaciy--------------------- Distance ---------------- lnearest well ------------ - rfoundation ___Distance to nearest lot line---_____________ Number of IneS -- -- Legth of each line -- - Widthtrench .Qw 1 of trench---------------.-_-.---------------`14 pag Pit: Distance to nearest well--- ` � Type of filter material--------------•----------Depth of filter material---_-.-----------------Total length____-._._____________-______________---- See _---A1Q.______Distance from foundation------I6_...------Distance to nearest lot line----- _.-__ Number of pits------------t--------Lining material---------Ox W. _--._Size: Diameter--------- ----_--------Depth-----------XS-i --------- Cesspool: Distance from nearest well_ _____________Distance from foundation-------------------.Lining material--------------------------.......... ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well.-------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot I;ne-------------------------------------------------------------------------------------------------------------------------------------------- - Re del' gand/or repairin (describe):___-_______L�✓� ` _____________ ____ - - - , ----------------------------------------------------------------------------•-•-----•---------------------------..-----•---------------------------=---- .�, ----- --------------------- --------------------------------------------•-•--------•----------------------------------•-------------------------------------------------------•------------------------------- - I -------------- - 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, nd rules, ,nd regulation of the San Joaquin Local Health District. (Signed) ° 1 l �edn Owner and/or Contractor) By:----------------------------- �--- - --- -----------------------------------------------------------------(Title (Plot plan, showing size of , location of system in relation to wells, buildings, etc., can be erse s ). ------------- 7- By: FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- -------------------------------------------°--------- DATE ------------------------- )j)---"--- ----------------- REVIEWEDBY---------------- ------------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------- --------- ' BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------:---.- DATE------------------------------------------------------------- Aiterationsand/or recommendatiisons:------- ----------------------------------------=------------------------------------------------------------------------------------------------------------ r -------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ------------------------- ------------------------------------------------------------=----------- ------------------------------------------------------------------------------------------------------------------------------ ------------------- ---------------------------------------------- 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 8-51 Revised W-2100