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jo- s M APPLICATION FOR SANITATION PERMIT � � � Permit NOA", • / kr (Complete in Duplicates) Date Issuedkj 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 Counfy Ordinance No. 549• JOB ADDRESS AND LOCATION___ C 7k� _ ,r Q Owner's Name................' - - - ••--- --- ----------------------------------------- Phone.,? ---,�-1------------ Address -------------- 1:,4? Contractor's Name ----------------------- - ------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ t Number of living units: j____ Number of bedrooms --,- Number of baths _/____ Lot size -------------------------------- Water _______________Water Supply: Public system A 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 ' Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ 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- ?'�C___Distance from foundation---t a_ ____.Material_ u + f-______ -- ---- - -------Liquid depth---- --------Capacity---��--- - �' No. of compartments_________��_.________._Size._/ �-� iC`tZ- Disposal Field: Distance from nearest well_?t�Distance from foundation---/1_.---------Distance to nearest lot line__S—*-_____ Number of lines_____________ ____ Length of each line____ �_�__- Width of trench_-__ - _�-�_________________ 1� � - - ----- g r•---------- Type of filter materiaf-_- -------Depth of filter material___i_3---------------Total length_____I- _0__'___________.-_---___-__ Seepage Pit: Distance to nearest well--.._________________Distance from foundation--------------------Distance to nearest lot line.--_-_--_________ ❑ Number of pits----------------------Lining materiaE-------.---------------Size: Diameter--------------- ------Depth--------------------------------- Cesspool: Distance from nearest weiL________________Distance from foundation-------------------.Lining material_____.____._.____-----_-____________. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest we#I-------------------------------------- _.:_•_-.-Distance from nearest building------------------------------------------ I] Distance to nearest lot line 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 County ordinance411elaws, and rules and regulati s of the San Joaquin Local Health District, i (Signed)-.- c.'l � (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 REVIEWED 'BY VVDATE__ ��.._ BUILDING PERMIT ISSUED------------ ------ DATE Alterations and/or recommendations:__--- -- _ - --- -- - .rr.-------------------------•---------:---------- ------------------------------------------------------------------------------------------------------------ -------------------------------------------r--------------------------------------------- --------------------------------------------------------------------------------------- FINAL INSPECTION BY:-c7— -____________ - Date ' ------ -----12 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9---:2M 8-51 Revised W-2100 I