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1 �7 A APPLICATION FOR SANITATION PERMIT Permit No_ _____ _ ____ (Complete in Duplicate) a Date Issued . Application is hereby made to the San Joaquin Local Health District fora permit to constr a install wor her i descri ed. This application is made in compliance with County Ordinance No. 549. 7� G4d 7L�� JOB ADDRESS A LOC ON.- M ------------------ ' Owner's Name--------- -- ---- - - - ------------ --- --- --- ------------ ---------------------------- - - Phone------------------------------------ Address------------------ -------------------•---•-----------Address-------••--------- ---- I----- ------ ---- --- Contractor's Name----------------- - -- - -------------------------------------------- ----------------- -------------- ----•----------------------- Phone----------- ------ Installation will serve: Residence° partment 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,X Depth to Water Table _ _ f t. Character of soil to a depth of 3 feet: Sand ❑ GravelSandy Loam ElClay Loam ❑ Clay El Adobe El Hardpan ❑ ty Previous Application Made: Yes ❑ Nok New Construction: Yes Y"1 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep i Tank: Distance from nearest well__ _;/__ __Distanc r found on____ No. of compartments______-__ -_Size--- depth_____________,--___Capacity____ _-__- -- + Disposal Field: Distance from nearest we1l_.%5b _Distance from foundation____-----__,Distance to nearest lot'Jhne___��_____ Number of lines______ __-________ Length of each line--------- Width of trench-._.Z. r Number __ rr `� Type of filter material-_-, � . L-Depth of filter material____-_ __ _____-_Total length_-----------_--"T_a-------------- See a e Pit: Distance to nearest well--- @_Q._�'----Distance from foundation____�_P___. isfe e to nearest lot lin ._.- Number of pits-------1____._____-- ate 'a� _ '---- ----------Size: Diameter-_" - ---------Depth------- -j-----------------� C spoof: Distance from nearest well_______________�D' tante rom foundation_-----------------..Lining material- ____-_____-_-_____-._ ❑. Size: Diameter---- ---------------------- _ :::r Liquid Capacity- --gals, Depth--------------------------- Privy: Distance from nearest well----------------_--------------------_-----------Distance from nearest building-.------------ --___--________-_ ❑ Distance to nearest lot line-- -------------------------------------------------------------------------------------------•--------------------------------------------- Remodel' a d r repairing descri e t-J___ __ .�+ + ll+� r �'---- --- - -_ ------------------------- ----------------- -- --------�------------------------ ------- - ------- SI hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin County ordinances, State aws, and rules sseagnd regulations of the San Joaquin Local Health District. (SignedK------ ----- � 4 -------- --------------------------------------- -- ------(Owner and/or Contractor) By:�-------------------------------------------•--------------------------------- (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------ ---- --- ------ t REVIEWED BY-------------- ------------------------------ DATE BUILDING PERMIT ISSUED------------------------ - ---------------------------- DATE:.---------------------- Alterations - ----------------Alterations and/or recommendations--- - -------------------------------......... _ ___ � �. - d�- F --------------- -- --- -- f ---- ----------------- ----------------------------------------- ----------------------------------- ------------------------------------------------------ -- -------------------------------------------------------------------------------------- ------------ -__ , ---------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:- -- ----------------------------------------- Date " ' --- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ' " TS 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 to-52 Revised W-2100