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APPLICATION FOR SANITATION PERMIT Permit No. - ------- (Complete in Duplicate) Date Issued /a`--� l Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. V -{This application is made in compliance with County Ordinance No. 549. , �. �.1. -_--------•--------------------------------------------------------- JOB ------------- ---------------------- JOB ADDRESS AND CATION---- ----- - f Owners Name-------- - ---- --.---- -- - ----- - ----------------- ----------------- Phon r t�I J --- ------------------------•--------------------------------------•-•--------------•--_• Address--- _ - . --- ---------------- -_ - ---- ---------- --- Phone------------------------•---------- Contractor's Name------------ ---- Installation will serve: R 1 enc Apartment House [ICommercial ❑ Trailer Court ❑ Motel Other ❑ 0-1 Number of living units: _/-- Number of bedrooms j---- Number of baths -- Lot size �./y .f_•--10------------ t Community system fl Private E] Depth to Water Table -------- ft. Water Supply: Public system Character of soil to a depth of 3 feet: Sand ❑ Gravel [j Sandy Loam El Clay Loam [I Clay E] 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_________________Distance from foundation--------------------Material____--__________________.____...____________.___. o. of compartments--------------------------well Size -Liquid depth--------------------------Capacity--------------------- � Disposal Field: Distance from nearest well__________________Distance from foundation_____________-____.Distance to nearest lot line.____..______._._ ❑ / I Number of lines-----------------------------------Length of each line----------------------_- Width of trench---------------------------------.. Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------- ..___._.Distar�ce to nearest lo# line_ -Z i Seepage Pit: Distance to nearest well--- -----------Distance f. m fouG ation___ ----- 7✓/_�t-_Size: Diameter_' _6_------------Depth__-�^+ ,. ------------------ Number of pits.________-_�_______-Lining material -__ti__ -__� Cesspool: Distance from nearest well______________--Distance from foundation-----------:----___.Lining material______--_________________________-__. ❑ ---------- Depth----------------------------------- ---------------Liquid Capacity------- 9als Size: Diameter------------------------- . ... - Privy: Distance from f Barest well------------------------------ ------------------Distance from nearest building_----- ❑ Distance to nearest lot line-------------- - --- ------------------------------------------ ------------------------------------ Remodeling and/or repairing (describe):- -------------- t�,_c�7rc�-----•--------------•--------------------------- ---- - -------------------------------------------------------------------------------- ------------------------------•----------------------- -- -------------------------------------- ---------- --P --------------pp-------------------------------------------------------------------------------------------•----- ---------- hereb certifythat I h� re aced this a licafiion and that the work will be done.in accordance with San Joaquin County ordinances, State an ,r les a regulations of the San Joaquin Local Health District. --------------- (Signed) ------------------------------------- (Owner angor Contractor) By -- ------- t ------------------------------------------------------- ------(Titl - - ----- ----- _ ----- (Plot plan, showin sise of lot, location of system in relation to wells, buildings, etc., can be pal ced on r erre side, k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY `" DATE'S- --------------------------------------------------- REVIEWED BY--- ------------------------------------------•- ----------- --------------------- ..._ DATE BUILDING PERMIT ISSUED------------------------------- ------------------------------ ------------------------------------- DATE------ ------------------------------------------- P Alterations and/or recommendations:-------- --- -------- ------------------------------------------------------------------------- } ----------------------- ------------------------- --- l - ------------------------------ "7 -------------------------------------- l FINAL INSPECTION BY:----_,_/_ --4K�------------------------ Date-.--- . SAN JOAQUIN LOCAL HEALTH DISTRICT 3oo West Oak Street 132 Sycamore Street North "C" Street 130 South American Street 814 TracCalifornia r a Stockton, California Lodi, California Manteca, California y s ES=9-2M B-51 Revised W-2100 i