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�U APPLICATION FOR SANITATION PERMIT Permit NO. -------- ' (Complete in Duplicate) r �1f licate) Da"'e 'IssueWd ` - Y "Ap hcation 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 Ordinance No. 549. ; Va. - -------------------------------------------- JOB ADDRESS AND LOCATION------------ - ------------------- Owner s Name--------------Lt1 D-s------------ --t ^'� Phone------------------------------------ Address-------- ------------------------------------ sPhone----------------------------------- - Contractor's Name-------------------------- ---------------------------------------- Installation will serve: Residence � Apartment House [-ICommercial [I Trailer Court El Motel [I Other Number of living units: -------- Number of bedrooms ____/_ Number of baths j---- Lot size __- a C---------------------------- i Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, ( Hardpan ❑ Previous Application Made: Yes ❑ No 14 New Construction: Yes ❑ No 14 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r r ' Septic Tank: Distance from nearest well---- Distance from foundation____.L .__-____.MateeL______________________ No. of compartments----------- - Size Liquid depth t'� - Capacity------, T- c Dis os 1 Field: Distance from nearest well__�U______-.Distance from foundation----(4_----------Distance to nearest lot ,,----`------- -7--`5-----------Width of trench--------- , -..Number of lines_____________ 4 -Length of each line,_ ._ 4 Type of filter ma -- �-Depth of filter material____-_-__� _--------Total length---------------- -- ------------------- Seepage Pit: Distance to nearest well---------------------__Distance from foundation__- ____.Distance to nearest lot line____-- ' Number of pits----------------------Lining material---------- -------Size: Diameter--------------- -----Dept h--------------------------------- Cess❑pool: Distance from nearest well-----------------Distance from foundation_._.--_________---.Lining material.________ ___. ____.__Li Liquid Capacity _________gals. ❑ Size: Diameter--------------------------- Depth q p Y ;. Priv Distance from nearest well-------------------------------------------------Distance from nearest building----------------------•------------------- y: . . --- _ El Distance r.to nearest lot line--.-_--- _ Remodeling and/or repairing (describe)----------------------------------------------------------- ----------------------------------------------------------------------------- ----------------------------------•------------ ------------ - - - ------ -------- ------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanVe,, tate laws, and rules and regulations of the San Joaquin Local Health District. (Signed --0 �-- {Owner and/or Contractor (Title By: -------------_--- --- ----------------------- ( i ) (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 DATE--------------- APPLICATION ACCEPTED BY________--------------- �. �-- -� ------- ------ REVIEWEDBY----------------------------------------- ---------- -------------------- ------------------------- BUILDING ----------------------- BEJILDING PERMIT ISSUED----------------------- --------- ---------- ---------------------------------------------------- DATE----------------------------------------------------------- Alterti ns and/or recommendations:.__ __- ------------------------, ------- ------------------- d c- � __=_= _ __::: __ y= = -------------------- . -- -- - --------------------------------- A ------ ------------------- ------------------- -------------------------- ::---- --___------------------------------- ----------------------------------------------- --- ------------------------- -- -- --------- -- -=- -- ----- - ----------------------------------- FINAL INSPECTION BY------------ - ----------------------- ----- Date i t a--- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street HO South American Street TracCalifornia Stockton, California Lodi, California Manteca, California y, J Y � .{' E5-9-2M 8-51 Revised W-2100 J