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J� _ Permit No. -,;.!oAPPLICATION FOR SANITATION PERMIT 1� (Complete in Duplicate) ---- Date Issued __--- ___-___/� I Application is h)eby 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 withCounty OrdinancQ Na. 549. f 4 �� f�j �r-Jl--`--------••---------... -----------• ---------- JOB ADDRESS AND LOCATION _________________�___ _ - ^`'ff Owner's Name _! _._ ----------------------------- ----- --------- ---------------------- ----- - Phone__-".1.1'_- -t-•--- ----- --- --------------------------------------------- ----- ---— -----•--•-----•-----------•-••---•-•-------------------- Address---------------•• --- ----�---`r..-.:-------- - ----------------••---------------------- •----------------------•------- Contractor's Name--• -•-------------------- ------ - ---------------------------------------------------------- Phone_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ O+hej ❑ Number of living units: J- Number of bedrooms ___/--- Number of baths __1----- Lot size ------------------------------ 171Private ❑ Depth to Water Table ________ ft. Water Supply: Public system Community system Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam jay Loam ❑ Clay ❑- Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Eil/ New Construction: Yes 19 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------_----------Distance from foundation--------------------Material-_-__________________..___--___________..____-- ❑ No. of compartments_ - Size Liquid de�lh. - CapacitY --------I ` Disposdl Field: Distance from- nearest w ll.��_Distance from foundation--- ____!_'_._.Distance to nearest lot liner,_ --_______- Number of lines___.__.___ ___ Length of each line__-.------- __ -.-_.Width of trench°_____ l '`_________________� g f Ike th of filter material____.___. - _-- _._Total length_________ _ :_____________________._ Type of filter materi T__ p �` ----------------------Distance from foundation_____________ f Seepage Pit: Distance to nearest well.._._ _____.Distance to nearest lot line_________.___.._ ❑ Number of pi+s----------------------Lining material-----------------------Size: Diameter------------------- -- Depth--------------------------------- Cesspool;., Distance from nearest well-----------------Distance from foundation--------------------Lining material___.__._.____._.._---_-_____._____._. Size: Diameter------------------------------- ------Depth----------------------------- ----------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-------.---------------------------------. ❑ Distance to nearest lot line -:---------------- ----------------- ------------°=-------------------------••------------------------------------ Remod n ,an or re airin dese'. 9 p 9 kms. _. ........ ' ----- - - -------------------------------------------------------------- 4 -a____________________________•-_____._..._______---_________._____.________-________________--____________--__{____- -_---__.____________._.--- ________________________________ ____________________________________________________________________________________________________________________________________________________________________ I 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. (Signed)---- y ------- -------------------------------------------------------------------------------------------------------------.(Owner and/or Coritractor) By:. - �f 1_ u - _ ----------------------------------------------(Title) = (Plot plan, showi g size of lot, loc tion of system in relation to wells, buildings, etc., can be placed on-reverse side). " FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. - -------------- ------------------------------------------------- ------ DATE-5-- BY------------------------------- ;W",---------------------- --- --------•- ---------------------------------- REVIEWED' DATE--_�__-_'°•_-------'----------- -•-••---------------------- BUILDING PERMIT ISSUED-----------U---- ----------- ---- -- - ----------------------------------- ---------- ----- ----- DATE Alter fibres and/or r co .mendations---------------- - _ - ----- --- ` -------------------- ------------ - ------------ = ��......--• -------------------------- --------t-1- -------------- rnx4 _ ''�',' i 7- ------------ --------------- ---- ''------------------------------- -" `•� ------ -jl.----t- ..�1 ---- --------- --------- FINAL INSPECTION BY:;. ----------------------------------- Date------ '"" �".��' --------------_-------•--------- e-� � `- '''"� '� R SAN JOAQUIN LOCAL HEALTH DISTRICT , � - 130 South American Street 300 West pek Street 132 Sycamore Street 814 North "C" Street ! Stockton, California Lodi, California Manteca, California Tracy, California i E5-9-2M 10-52 Revised W-2100