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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 County Ordinance No, 549. JOB ADDRESS AND LOCATIO ___U'Lle ----.----__---- 6dk 1__450."---- -- --- -- ------ -------- - ----- -- Owner's Name------- @ • ...........-•------------------- ----- Phone. ---------- 11- Address - .-- -- ------- Contractor's Name-------...-- -------------------------------- Phone------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: _. '__ Number of bedrooms ___-- Number of baths ---/--- Lot size -___.-�_- . ------------------------------- Water ------------------------------Water SuPPIY� Publics stem ❑ Community system ❑ Private to Water Table 7 '� Zy ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes No ❑ TYPE OF INSTALLATION AND.SPEC I FICATIONS: _ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well..-.,f ,2:.__Distanc m • _ foun : ion_--o%-O-___.Mater�id.-i---- --------------------------------- --- � ��No, of compartments.__..;.__ Size___ _X_��_x--� '-Li2uid depth------ Capacity--- D -� --�` sal Field: Distance from nearest well_11_0.._Distance from foundation__. -----Distance to nearest lot line---A.Q__-_- Number of lines-------------vV-----------------Length of each line------1_1. ----- Width of trench--------��-_".__.-__ p �� Type of filter material--�-[�-- De th of filter matertal_._._�. __.._..___Total length_ e t �?_._._-----_--__--•- Seepage Pit: Distance to nearest well......................Distance from foundation--------------------Distance to nearest lot line---___._-.--_.__ ❑ Number of pits______________________Lining materia(---------------------- Depth._.Size: Diameter__...___....._.___.__ - r .. ---------------------- Cesspool: Distance from nearest well--------.--------Distance from foundation---------- ----.Lining material_______________________________ ❑ Size: Diameter--------------------------- ------ Depth.-------------------------- --Liqui Capacity. ------ Privy: Distance from nearest well.-.---------------------------------.-----------Distance from nearest building---------------------------- ------------- Distance ------------- Distance to nearest lot'line_-.__._._________________________ Remodeling and/or repairing (describe):---- ---- ---------------------------------------•----------••------------------•---- -----•----------• (r -----------•-----------•-------------------------------------•---•---------•-----------------------•--------------•---------------------- --------------------- - •---•-----••--•-------•----------------------------------------------------•---------------------•-••--------- ' ----------------------------------------------------••---•-----------•---------------------•--------------------------------•---•--------••--------•--...----------------•---------•-------•------------------------------- 1 I hereby certify that I have prepares this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and' reguf ions of the San Joaquin Local Health District. (Signed)-- - • ----- -----Z I -- �-- ------------------- ------�-- - ------- ------;------------- ------------------•--------------(Owner and/or Contractor) BY:---- ---------- -----------------------------•--- ------------------------------------------•-----------------------------------..(Title)----------------------- --------------------------------------. (Plot plan. owing size of lot, location of system in relation to wells, buildings, a+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --------- ----------------- -------------------- -- ---------------------------------------- DATE REVIEWED BY----- --------- ----- - DATE --- -_ BUILDING PERMIT ISSUED------------------------ s------------------- DATE. r ----------- -------------- Alterations and/or recommendations:-----.- ------- - --------------•----------- ---------------------------------------------------------------------------------- ------------ ---------------------------------------------------- -------------- -----•------------------------- ---------------- -------------------------- ------------------------- -- -- ------ ----- -----------•• ...-------------------------------- -------•------------------- ------------------------------------ FINAL INSPECTION BY: Date-----------------L "`_ �. ---------- ---------------- SAN ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT �sf 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street r+�� Stockton, California Lodi, California Manteca, California .Tracy, California F E5-9-2M 1454a6 aT-Dan 1254