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s� APPLICATION FOR SANITATION PERMIT Permit No. __c`t_/----------- f !� -- •- - (Complete in Duplicate} 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 Ordinance No. 549. JOB ADDRESS AND LOCATION.------ Owners Name --------- - = Address---.-------------- - ------------------------ Phone- -- r---_4._. ---------•--. ------•--- ------------- Contractor's Name_--- Installation Installation will serve: Residence ---------•-`- -------------- Phone---•--•----------- partment House -----•-------�--- Number of livingunits: _ ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] --- Number of bedrooms f Number of baths ___--- Lot size __Water SuPPIY� Publics stem ------ X mmuity system Private [I Depth to Water Table Character of soil to a depth of 3 feet: Sand ---__--- ft. ❑ Gravel ❑ Sandy Loam ❑ Cla Loam Previous Application Made: Yes ❑ No � _�ey- ❑ Clay ❑ Adober�--k{ardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Yes l±�No ❑ (No septic tank or cesspool permitted if public sewer is available within 208 feet.) S ptic Tank: Distance from nearest well-_--------------Distance from foundation___--._ No, of compartmentsSize ----.Material ----•-Liquid depth --------- Disposal Fiel Distance from nearest wel ----__-Capacity_____________ ___ ��` Distance from foundation___� _ Distance to nearest lat line,,--4' of lines____________ _ Length of each line--_____•-_ ____ f� Type of filter material---_�}- __Depth of filter material__�.�-�-_ �=W�dth of trench--.-___�-_�___ ------ Total Seepage Pit: Distance to nearest well---------------------Distance from foundation---------.----------Distance ntto nearest to*lliineA--- ❑ Number of Pits----------------------Lining material----------------------- � Cess ool: ----------------Size: Diameter-__---______ _ P Distance from nearest well-----------------Distance from foundation _-----.----_ --Lining material -_--- Size: -------- Depth --- ------------Liquid Capacity---------------- Y: Distance from nearest well--_-_-___---___ ------gals. ❑ Distance to nearest lot line--------------- __ _____ Distance from nearest building-_-_----_-_-___- ___-_ ------•--------------------------------------•- 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 Count ordinances, State laws and rules and reg a+ions of the San Joaquin Local Health District. r E Y (Signed)__- $ (Owner and/or Contractor) ------------------------- ------ ----- - - ---(Title)--------------------------------------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, efc„ can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ r_-_--- ---—-------------------------------------------------------- REVIEWED BY------------------ DATE -= - UILDiNG PERMIT ISSUED-- DATE r - - ---------------- - --------------------------------------- ----------- Alterations and/or recommendations: _-__-_ -- DATE---------------------- ------------ ---------- -----------------------------•------ r --------------- --------------- ---------------- FINAL INSPECTION BY:----- ---- --------- . .�- ---- -- ----- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reef 300 West Oak street 132 Sycamore Street 814 N Stockton, California North "C" Street Lodi, California Manteca, California Tracy, California + FS-9-2M $-51 Revised W-2100 {