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APPLICATION FOR SANITATION PERMIT Permit No. _ ___- __�---# 5 ,/ (Complete in Duplicate] Date`Issued _�_�t_ .�_ `'" 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 County Ord' anc No. 549. JOB ADDRESS A LOC ION-------- - r - ------ ---------".-------------- y ------------------- ----------- Owner's Name-___ - - ---------------------------- -------- -- ----- ----- - ---- Phone --- ------ ------------------- ------- Address.----- 4 --------- --------------------------- 's g ---•--'- Phone ----•---•-------------------------- Contractor's Name ------- -----__ - ' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motgl ❑ Other ❑ �` �._ - . Number of living units: ______ tuber of bedrooms __A- Number of baths _-- Lot Number Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _::_____ ft. d Loam ClayLoam ❑ Clay❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: 'fSan1 Gravel ❑ Sandy k t� Previous Application Made: Yes ❑ No New Construction: Yes No ❑ r , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool' permitteaU public sewer is available within 200 feeth j �" 0- '- Mat�eiia Septi ank: Distance from nearest we __ sista c�, 1frp and n'Ca aci-- 'Y�! P Y Size_ Liquid da'pthw No. of comparfiments______ ----�----�- r---- Dispos Field: Distance from nearest well___._ L)istance;from foundation_____tance`to nearest lot line)__ Number of lines ---------- - -- Length sof each line--- - ----------.Width of trench -- --------- --- --------- f Type of filter mate��P th of filter material-_.__+ -Total length_______-_--�___--------•---•-- Seepage Pit: "'Disfa—RE ye to nearest well _.__.____--___---- Distance 'from foundation --------------------- Distance to nearest lot line -----_____.______ � e ❑ Number of pits-- -------------------- Lining material ----------------------Size: Diameter------------------- --- Depth - ---------------- - --------------- w. T, . Cesspooi: Distance from nearest well-______---------- Distance from foundation_._--______-_s-`.Lining`materia--------------- --------------- als. ❑ Size: Diameter ------- - ------------------------------ Depth---------- ----------------- ------------------------ Liquid Capacity---------------------------gals- El m Privy: Distance from nearest well ---------- --------------------------------------- Disfance from nearest building------.----------------------------------- ❑ - :---- ------=------ ----------'-------- --• Distance to nearest of ine------------------------------------ - - Remodeling and/or repairing (describe --------------------------•----•-----------------------------•----------------- ----------------------------- 9 =-------------- s ------- -- - - ----- ----------------------------------- --- I hereby certify tha+ l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and les and regulations of the San -J ruin Local Health District. , { (Signed) ----------------------------------------------- ------------------- (Owner and/or Contractor} t --- ------------------------------------------ Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed onIreverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B --------- ----------------------------------------------------------------- -- DATE_- REVIEWEDBY--------------------------------------I-----------------DATE----- BUILDING ----------------------=---------- --------------------- DATE----- BUILDING PERMIT ISSUED___________ ____ ------ ------ DATE------ --- Alterations and/or recommendations:----------------------------------------------- ----- ----- r --------------•---------------------------------- FINAL INSPECTION. BY.-._- -- ------ - ----------------------------- --- � -Date-- - ----=---- ------ -----•--•---------- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y� E5 -9-2M : LRevised W-2100