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� 1 � 555 Ak APPLICATION FOR SANITATION PERMIT ' Permit No. __ /_ (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 Cunty Ordinance No. 549. t xt 0OB ADDRESS A LOCATI N-------- `- --t----•------- " __._ _ A-_______ _ _ I _ Phone--------------------------------- wner's Name. /._ ------- Address-----_------- -' one. -- -- ---...1 ------ - --- ----- Contractor's Name_ -- ---------- ---------------- -- ------- one will serve: Residence Apartment se ❑ Com ercial ❑ Trailer Court Mote ❑ Other [� €i 1 Number of living units: --I♦---- Number of bedrooms .,c,�_ Number o. baths ___�__ Lot size ___ - f_ .______ --..f-- - ----- Water Supply: Public system ❑.-Community system ❑ Private Depth to Water Table .___ tt. �iCharacter of soil to a depth of 3 feet: Sand Gravel E] Sandy LoClay Loam E] Clay ❑ Adobe Hardpan ❑ ;Previous Application Made: Yes ❑ No ;-'-No " New Construction: Yes E:1 €1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I?Septic ant: Distance from nearest well__ ..__:Distan e7 fro fou datio _____�Q_--____.Materyal__.____.____ --- No. of compartments Z ------Size l id depth 5 Capacity r I, Dispose ,Field: Distance from nearest well-.__-----Distance from found Number -.______Distance to nearest lot i��._.,�____.__. Number of lines---.�:1------------------ ---- --Length of each line------ '�--�t-------Width of trench --- _- ' /---------_-- Type of filter material=_ -Depth of filter mater€al____._�-?__._!____Total length__________________ �---------------- E� - 5eepa it: Distance to nearest:welL._._� .____-=Distance f m�fo ndation?__. 1 __..___.Dis ns�e to nearest lot .____ Number of pits-------r------------Lining material---, ��-�ize: Diameter------ ----------.Depth--------/K?-------------------- Cesspool: Distance from nearest well_________________Distance from foundation__-----______*.__.Lining material___--------__________________--__.__. ❑ Size: Diameter------------------------------------1 Depth:---------------- ' Liquid Capacity gals iiPrivy: Distance from nearest well-:_._____.---�__________ ____________ ___ ______Distance from nearest building-------------._______-_-_______--___.___. �� ❑ _ _ . --------�,---------'".� ` ;--- -.-------"�.----------------�---------------------------- --- I ..�. .1 ' Distance'to neatest line-------------- -�-------------------- -- - Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------------•---- ------------------------------------------------ ---1-1------------------------------------------- t �F _________________________________.___-_ _______________4_-_______-_...._______.___.________�.-._______._______..-______.._______..____________. i ------------------------------------- ---------------------------- --------------------------------------------•----------=---------------------------------------------- i I hereby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin County ? ordin to IASL and rules and egulations.of th an Joaquin LocalHealthDistrict. E - - --------- -- ---- . -�` " ---- cpm) !� (Signed•___-- -- caner and/or Contractor) i� r --------- - ------------------- By- v .... --- - --- - ------------------- Title '!°_. i (Plot plan, showing size of lot, location of system in relation to w s, buildings, etc., can be placed on reverse Ode). --FOR DEPARTMENT USE ONLY E� APPLICATION ACCEPTED BY------ ------ ------ DATE ------------------------------------------ €1 REVIEWED BY_____-- DATE______"_. - iDATE------ ----------^ ------------------------------------- Alterations. ---------------------------------- €� BUILDING PERMIT ISSUED--------------------- ----- ----------------------- ---------------------------------------•----- ii Altera+ions.and/or recommendations:---------- - -------------------- ----------------------------------------- -----:-- :::----=----- ---------_ €� - �k ---------------------------•-------------•---------^-----------••-----_.-.._..•- ---... -- ----- ------4' k----------- --------------_--------------------------------------_____ __ ____________________________________________________________________________ _ l. _ _ _ _________________________________ ______________________________________________________ ___ .___-_____._...__ __._-_-_______ ____._..---�__-_..__-_______________________ _____ 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 cc—o��tA RRviznA W-2100