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E 6r APPLICATION FOR SANITATION PERMIT Permit No ___�?- -_ ___ (Complete in Duplicate) Date Issued _-`-/ a gplicafion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. �7zZ 1 JOB ADDRESS AND LOCATION----- ✓ --------- - --- ---- ---------- ► ----------------------------- Owner's.Name--- - ------- ---------------- Phone�_�4_6--- - - Address---- ----- ---------- Contractor's Name------ --------r .'-- �--- ,` - phone _ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [IMotel Other 171 Number of living units:/'a- Number of bedrooms _/QNumber of baths /0_ Lot size __. ---------------- •----------------:-------- Wafter Supply: Public+system ❑ Community system ❑ Private Depth to Water Table„�Q__ ft. a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ " Previous Application Made: Yes ❑ No ew Construction: Yes [ to ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: 1 [No septic an r cesspool permitted if public sewer is available within 200 feet.) } Septic Tank: a stance from nearest wel ------------------Distance"from foundation__________________ Material-------------------------------------._.____-__. ❑ o. of compartments---------------------- size--------------•K� Liquid depth--------------------------Capacity----------------------- �40__#--__-Distance to nearest lot line___��______. Disposal field: Distance from nearest well_�� _.__Distance from"foundation � � � �, I Number of lines_____ Length of each line7=�/ f _D__.Width of trench._ , ____________ Type of filter materialU�.�Depth of filter mat'rial____�- _ _.___Total length___ ____----------------- JI-IF , Seepage it: Distance'to nearest well-_�_, �____Distance from f ndation_ # Distance to nearest lot line _ ------ t� Number of pits____/________------Lining material- �},t, Size: Diameter__`_...________.Depth.___ -t________________ __ • Cesspool: Distance from nearest well-----_i---------Distance from-foundation-_.._-------------_Lining maferial-A.---------------------------------- ElSize: Diameter----------- --------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. .a el ' Privy: Distance from nearest well__________________________.__.___.-------------Distance from•nearest building-_-_.-.-______-_________-_______-.._____- ' ❑ Distancb to nearest lot line--------------- --- r ---- --------- -------------------- --------- ----------- Remodeling and/or repairing (describe)------------------ ---- -------- ----- -- ------------...----------------------------- - i ------- --- ----------------- - ------------- --------------------------------- ------------------------------------------------------------- ----------------------------------------------- •----------- ----� 1 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. ,. -------- ------- --------_____----_-__(Owner and/or Contractor) 1. (Signed)----•�---- - -- --�-�- --.- .r�l�-"!`-�'.�.,,,a__. ----- By.:---•--- ,- f [Title)---- Y �`� g p ) - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be laced on reverse side). rK FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED IIIj- -----------= —----- --------------------------------- ------ DATE--- - - --------------------------------------- k REVIEWED BY -- -- -- DATE-- --- - - BUILDINGPERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE--- ------ ---------------------------------------------- Alterations and/or recommendations * ---°--------'-------------------------- ------------- `-------- f ------ -------- '" ! s. " 'ht' . _± _._ _.'fi #_ F -`------ ---------------------------- -------- ----------- - ----- ------------ ------------ ------- --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------ FINAL INSPECTION BY:-- / ---_.. -------- - Date------ -------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 5-51 Revised W-2100