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APPLICATION FOR SANITATION PERMIT Permit No. __. _ _-----9-_- (Complete in Duplicate) M Y ' 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 LOCATION------. 11.A 0 ---,e- "'� --- ----- ----------- -----------------------•-----•------------ -------•--------- Owner's Name----. .s.�.-'1. -� . . . - -•--------- --- ------------ -------------- Phone--------------------------------_ �� _Address l Contractor's Name,4. r_ _e------------------------------------------------•------ --------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence R] Apartment House-❑:Commercial E] Trailer Court ❑ Motel E] Other El1 Number of living units: __.�____ Number of bedroo sNumber of baths�`�_._ Lot size --------------------------------------- Water Supply: Public system E3Community system El -P�vate ® Depth to Water Table 570__ ft. i Character of soil to a depth of 3 fee+: Sand ❑ Gravel [I Sandy Loam ® Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ : Previous Application Made: Yes ❑ No X1 New Construction: Yes ❑ No A] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SepticTank: Distance from nearest well----------------- ______________`Distance from foundation------------------°Material---------------------------------------------- ❑ No, of compartments----- --------------------Size----•--•------------------------Liquid depth--------- ------- --------Capacity----------------------- Disposa) Field: Distance from nearest well-_d` _____Distance from foundation_f_-_.._.__.__.Distance to nearest lot line.07/..-.____. Number of lines______________________________Length of each ----------Width of trench._iZ. or Type filter materiaDepth of filter material_!0A...........Total length--- Seepage en th__-Seepage Pit: Distance to nearest well______________________Distance from foundation_______.________.__Distance to nearest lot line_______________._ ❑ Number of pits----------------------Lining material-------------------.-..Size: Diameter-----------------.---.Depth.---------------------------_..._ 2 i Cesspool: Distance from nearest well--- -------------Distance from foundation--------------.-----Lining material-----------.---------------.--__---__ ❑ Size: Diameter------------------ ----------- -- ----Depth----------------------------------------------------Liquid Capacity-----------------------------gals. N Priv Distance from nearest well--------------------------------------- ---------Distance from nearest building------------------------------------------ +(�\, IlI' ❑ Distance to nearest:lot line--------------------------------------------------------------------- ---------------------------------------.---------.-------------------- � �I 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. c�-• - (Signed) , l ` - ---- aR-.� ------------------------------- (Owner and/or Contrac#or) By----------------------------------------------------------------------------------------- - ------------ --------_-•----------------(Title)--------------------------------------------- ----------------- .(Plot-plari;iliowing-size--f lot,-location af--system-in relation to=wells,-•buildings; a+c:,--can-be placed:on reverse side). _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - ----------- ----- ---------------------------------------- DATE----' ' •' -------------------------- I REVIEWEDBY--------------------------- ------------ ------------ ----------------------------------------------------------------- DATE----------- ----------------------------------------------- BUILDINGPERMIT ISSUED------•------------------------------------------------------•---------------------------------------- DATE--- -------------------------------------------------------- Alterations ------------------- -Alterations and/or recommendations: - ------------------------------•_.. -----------------------------------------•--- ------•-------•---------------------------------- ----------------------------------•-------------•-----•--••------••-----•-•-----•----•------------------------------- ------------ ------- ------------------------------------------------------------------------------------------------•- -------------------------------------------------------------------._..._...--- ------ ---------------------------------------------------------•------------------ --------- --------------------------------------------------------- ---------------------------------------------------------------------------- --------------------------------------------- ----------------- ----------------- ----------------------•---•-- --------- -•-------------------------------------- ------------------------------------ FINAL INSPECTION BY: ------- ------- ----•-- -------•---- Date._." l SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California E3--7 145446 ATW30D ' ~