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,�`�_ APPLICATION FOR SANITATION PERMIT Permit No. ____________________ (Complete in Duplicate) . Date Issued/�'--�� Applica*ion 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 9ounfy Ordinance No. 549. JOB ADDRESS AN L CAT CSN---- - ----- ------- --4 A- '? --------------- ---------- Owner's Name Phone a �✓f .�wra+________________ __ ____.....___________.__________.___ _.-.__ _X- -� ----------------- , s Address -�"---- -- ---- -- ------ ------- ----- ----- - --- - --------- ---------------------- Contractor's Name------ ------ ----------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installaflon will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ o/l ell Ot er ❑ Number of living units: _'____ Number of bedrooms __ __._ Number baths _l-____ Loti,e��40- 0.0..1_________________________Water Supply: Public system ❑ Communitysystem'❑' Private'�Depth'toWater .__"-_ ft Character of soil to a depth of 3 feet: ISand ❑ Gravel ❑ Sandy Loam ,❑ Clay Loam❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No V New Construction: Yes R(No ❑ I t TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if blit sewer is available'within 200 feet Septic Tank: Distance from nearest wellQ�' * �_[�_____.._._--. P - -- ------ ist �e fr m f�urfdation---- - Mater-a�--------- - •----------•--•-•- �----1--� a� f _ _ No. of compartments p t Size Liquid►depth ------ ----Capacity--- -1f r Disposal Field: Distance from nearest w I .__��j�.......Length of each line________________" f____..Width of trench.___.___ T e of filter materi i 1------------- yp .- -, .Depth of filter matena]______- - ---_F__---Total length----------f� ------------------------ Seepage Pit: Distance to nearest well ___________________Distance,from foundation _______.______.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material.-.i-------------------Size: Diameter-----------------------Depth-----------------------.---------- Cesspool: Distance from nearest welL________________Distance from foundation....................Lining material_-___-..._____._____-___-_________-- ' ❑ Size: Diameter-------------------:------------------Depth----------------------------------------------------Liquid Capacity------------ -------gals. Privy: Distance from nearest well----------------------------f""!'-------------Distance from nearest building----------------------------------__..-.. ) ❑ Distance to nearest lot line----------------------------- ;------------------------------------ Remodelingand/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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. i aM A_._:_ (Signed)------_�_-_�__ _ (Owner and/or Contractor) "J"' ' °'� By:---- y = ----- ---------------------------------------------- (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 = ------------------------------ -------- DATE BUILDING PERMIT ISSUED--------v---- DATE--------_-- Alterations and/or recommendations:----------------------------------------------------------------------------------------...----------------------------------------------...------------------- ------------------------------------------------------------------ -------------------- -------------- _�i ----------•----------------•---------------------------•-------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- ------•-------------------------------------------•--------------•------------------------------•--------- FINALINSPECTION BY------- -------------------•------------------------------------- Date---------------------__--------------------------------------------- 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 �• E5-9-2M Revised W-2100 `1 l..