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�t ` IA APPLICATION FOR SANITATION PERMIT Permit No. --- in Duplicate)(Completep } /D S Q� 1VDate Issued Application 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 withCountyOrdinance No. 549. " JOB ADDRESS AND LLOCATION__�/_, -------- ---------------------------------------------------------------------- ' Owner's Name-------- `_.!/ll'__------- - - ------ ------•-------••------------ --------------------- --------- ---------- Phone__` � . Address------l--7.?jg;-------- -' ------- --------------------------•---------------------------------------------------------------------------------------------- ------------------------- Phone-----Contractor's Name. {� Installation � will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ i �-10OA � I Number of living units: __�__. Number of bedrooms ___c�Number of baths __�__ Lot size _____________ _____________________________________________ i Water Supply: Public system x Community system ❑ Private ❑ Depth to Water Table y0_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)' Hardpan ❑ Previous Application Made: Yes ❑ No 07 New Construction: Yes ❑ NofRT' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Tank: Distance from nearest well_________________Distance from foundation--------------------Material____.---------------------------------------------- ! No. of compartments--°--=------- ------------Size--------------------------------Liquid depth--------------------------Capacity- .: -_----- ` Dis al,Field: Distance from nearest well-________________Distance from foundation--------------------Distance to nearest lot line-------.......... p , �� Number of lines---------------- ------------------Len.gth of each line-----------------------------Width of trench----------------------------------- T -------------- ---- \ � Type of filter material________________________Depth of filter material_--.----._-:__._______-Total length_________________---. --_� -_ . ---------------- If Seepage Pit: Distance to nearest we11__NQNE_.__Dis e from,fou tion-___7a________.Distance to nearest lot line---__- 40....... Number of pits-------/-----------Linin.g terial_S�- h� __-5i e: Diameter-_--_-_�-.___-----Depth-------i5.,------------------� i Cesspool: Distance from nearest well----___--_-___-_ nce from foun ion-_--_______:_____.Lining material---------____________________________. ❑ Size: Diameter--------------------------------------Depth----------------=---------------------------- ------Liquid Capacity----------------------------gals.- Privy: Distance from nearest well------------------_------___--------------------Distance from nearest building_____--_---_-_-____________-_-_---____._. ❑ Distance to nearest lot line----------------------------------------------- -------------------------•------------------------------------------------------------------- Remodelingand/or repairing (describe):-------------- ----------------------------------------------- ---------------------------------------------------------•-------------------------- =( -------------- --------•--•-------•-•---------------•-------------------------•-----•-•----------------------------------------------------------------------------- -------•-------------------•-------•--------------------•---------------_-_------------------�---------......---------------------------------------•------------------ 1 -------------------------------------------------------------------------------------------------------------------------=----------------------------------------------------------•----•----------------------------------- 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. lt (Signed) ---- ------- ------------ - ------------------------------------------------ ---- ------ wner and/or Contractor) TBy: ---- -- - ---------------- ----•---_ ------------------------------- (Plot - - (Plot plan, showing size of lot, locati n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ ,,__ _ ----- --------------------------------- -------------------------------------- DATE ----------------- --------------------------- DATE-_ - ---------- ------ - REVIEWED BY �' DATE-- ------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------------------- DATE.. �13 �. Alterationsand/or recommendations:--------------------------------- ---°-- -----------------•------------------------- .---------------•-----___--•-----______-_---------•-•------•---------•--- -------------- -•-----•------------------------------------- •----------------------------------------------------------------------------------------------------------------.•--------------------- -------------------•-------------------------- -----• --•----------------------------------------- ------------ ----------------------- -------------------------------------------------------------------------- r ----------------------------------------- ------------------------ . ---------------•---------------- FINAL INSPECTION BY-------------- '' ---------------------------- -------- Date -- --- t- ---�-.---- -------- ----------------------------------------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132.Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Rovised W-2100