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Val `, a '� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ P P ) tJ' Date 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 with County Or ante No. 549. r � . JOB ADDRESS AND LOCAT .._, L i- yJ� Owner's Name... -------- ----- --- ------- --------- - -- .---------------- --------------- -------------------------------------------- Phone------ - --- ........ AddressWit"'- = "= -— ----------------------------------------------------------------------------------------------------- Contractor's Name.... ----•--- --------------------------------------------------------------------------------------_- ----- Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court F] Mo�el ❑ Other E]Number of living units: ---L umber of bedrooms __�_. Number of baths ___I__ Lot size -C5'P---x._`1/_tl_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand Gravel [:] Sandy Loam Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public S" is available within 200 feet) Septic,Tank: Distance from nearest well0 ------ _Dista cp fro foundation___ Maters {�1 No. of compartments------------ nn,------_-Siz 1�___O_-xL1�---Liquid FIepth---------_�----------Capacity---.��t Dispos Field: Distance from nearest w l v___•____-_Distance from foundation_/ll_.`'__ti'."`'bistance to nearest lot line _ Number of lines___...____ __ l �i -------_--- ___ ___ ____ Length of each line_______.______:_.__ Width of trench_______._ _ T e of filter maters rt / t yp pth of filter material________-_Z_____.__Total length..............1________�__-..._._____._ Seepage Pit: Distance to nearest well_____________________Distance from foundation....................Distance to nearest lot line----------------- 1-1 Number of pits---------------------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-______ ______________________V______--Distance from nearest building______-___________--_____.____._______- ❑ Distance to nearest"Iof"'line--- - ------ - - ------------------------------------------ Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------- ------------•------•----------------------------------------------------------------------•------•-•----------- --------- -------------------------- -----------------•------------------------------------------------------------------ -------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that fhe work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regula ions of the San , aquin cal Health District. (Signed)_ �� - o ==' - - - ----------------------------------------- ------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------- ---------------------------------------(Title)---------------------------------------------------------------- (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 APPLICATION ACCEPTED BY ---_-------- DATE REVIEWEDBY •- --------- -------- -- -- ------------------------------- DATE BUILDING PERMIT ISSUED--------------------------------------------------------------------- ------ DATE---- U--------- - Alterations and/or recommendations----------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------_-.-------------------------------------------------------------------------------------------------------------------- --•--------------------------------•--------------------------------------- ---------------------•-----------------)----------------------------------------------------------------------------.--------_--------- -------------------------------------------- FINAL INSPECTION BY:.--------- --•- - - ------- ------------------------ Date------ /?3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100