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APPLICATION FOR SANITATION PERMIT Permit No. `' ' --- (Complete in Duplicate) Date..Issued /-""" ! --- Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 3 This application is made in compliance with County Ordinance-No. 549. i 1 s JOB ADDRESS AND OCATION" - ------=----- ' --- - -- ----------------------" ---------"__---------------'_----.--------- n,� ri - ------ Phone-_--_ :---- Owner s Name- _ ----- ------ ----- _ '.. R ---------------------------------------------------- - ------------------ ---_ ____... Address - - ------------------------------------------ ------------DC4� // Phone---�--'c•• "-. � --------------------------------------- Other Contractor's Name---------------- - - -- ----'----- ----------- ----- - Mote! Installation will serve: ResidenceX.Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑ Number of living units: ---/- Number of bedrooms "2 - Number of baths _ _---- Lot size ---- -f �.��a---------------------•-- Water Supply: Public.system Community system El Private ❑ Depth to Water Table --_C1ft. , (� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hard pan ❑ +�� Previous Application Made: Yes E]: No New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: T O F '(No septic tank or cesspool permitted if public sewer is available within 200 fee+.) f ------ ._ Septic T nk: Distance from nearest well----"-----"-___""Distance from foundationMaterial------------------------ --------------- • No of compartments--------------------------Size--------------------------------Liquid depth---------------- --------Capacity---------------------- isposal eld Distance from nearest well----------------".Distance from foundation--------------------Distance to nearest lot line---_ __---_-__- k . Number of lines--- ------------- ----------------Length of each line------------------------------Width of trench-------------------------------- •- Type os filter material-------------'--------Depth of filter material-------------------- t'_Total length__I_-------------------------------•- v\` x 4_ Distance to nearest lot e"14! Seepage Pit: Distance to nearest well.,, `'_--Distance fr m fours tion_""_ "_" " pSize: Diameter------ -------- ---Depth----- ----- -- t----- Number of pits .- "--------------Lining material__" _ Cesspool: Distance from nearest well-_-_-_-_------_Distance from foundation--------------------_Lining material__""- `..gals. Size: Diameter------------------------------------- Depth--------------''-------- ---------------------- ---- Liquid Capacity---------------- ------`-•g OL Priv Distance from Nearest well--------------"."------------ ------Distance from nearest building-----.-.---------------------------------- Privy-.. ` ---- ------- Distance to nearest lot line-- - = Remodeling and/or repa4ring (descr ) ---- ----- t •----- --- ----- ---------------------•-- -----------•------ _r n --------------- --------- ------ --- by ce �fy that I ve prepared +his a r ication and that the work will be done in accordance with San .Joaquin County I here r ordinances. Stat ws,'an ides and regulatio sof the•San Joaquin Local Health District. (Owns ontractor) ,w (Signed)----._ rand or + �' { � ---------- ---------------------------------------------------(Title)- - _7 (Plot plan, showing size of to+, location of system in relation to wells, buildings, etc., can be pla on reverse s de). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE-- ------------------------------------------=---- BY-------------------------------- — ----------------------------------- •----------------------- DATE ----BUILDING PERMIT ISSUED --------------------- DATE --------------------------------------------------- REVIEWED ~ = - --------��`--'---------------------•------------------ Alterations and/or recommendations:--------- -- -------------- ------------ ----------------------------------•----- - ---,--;- rK v 1. lir"_"""""""___"."""""-.-""""""___"""___•-----------------......------ ---------------------------------------- "_._____""".""_ ----- ------------------------------- .""""".""_"-. ----"" -------------------"_------------_------•---------•-_---__-------------- 4. ----------------------------------------------------------- -----------------------------------------------------"-- -- FINAL INSPECTION BY:.-_"---- "-- - •------- 'Date--- � --- ��-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lalli, California Manteca, California Tracy, California E5-9-2M : Revised W-2100 }