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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicatel / Date Issued 1!Z_— .S 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION.. _ - +° --- -_-_ , , Owner's Name--------------------- � fit/,-- --- ........... ---•--•- Ph--- ----------------�- �-------- -- ---one.---•----------------------•-------- Address- ---------.1.► -1-. -------- •-C� (0------- Contractor's Name--------_------- --- -------- ------ ------- Phone Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms -----�._ Number of baths _t0--- Lot size -------- ,�,,,.� ------------------ Water Supply: Public system ElCommunity system ElPrivate [j/ Depth to Water Table _77k- ft_. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation___________________ Material { No. of compartments--------------------------Size--------------------------------Liquid depth-------------- ----------i Capacity------- --------------- Disposal ----- T-= "Disposal Field: Distance from nearest well----------------__Distance from foundation--------------------Distance to nearest lot line----------------- El Number of lines-----------------------------------Length of each line-----------------------------.Width of trench- n Type of filter material-------------------------Depth of filter material----------------------.Total length------------------------------ Seepage --_--_-- -- - -------------Seepage Pit: Distance to nearest well------.5*Q------Distance from foun tion----!p_-------Distance to rest lot line.._ �. Number of pits--------I-----------Lining material_ „44/�ze: Diameter-�__.�--�}� pth_____-----�- ---�--`-� � Cesspo� I: Distance from nearest well-------------_---Distance from foundation_-------------------Lining material__.__:_______-__.______._ - 1 Depth ❑ Size: Diameter ------ -----------------LLiquid Capacity.-,.,, Privy: Distance from nearest well-------------_-----------------------------------Distance from nearest building-------- ` ❑ Distance to nearest lot line. Remodeling and/or repairing (describe)......... .--__------_--_ --------------------- e done in accordance with San Joaquin County ! hereby certify that I have prepared this application and that the work will be ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Si ( 9ned�60 -x'' ----------- -------------,--•-------- -------------- -------------- - - -- -- caner 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 _ ,y APPLICATION ACCEPTED BY------------------------------- ------ ----------------- ----------------•---------------------- DATE-------------- -- ------------------------------- REVIEWED BY----------------------------------------- ------ ------- - --- --- ------- ---------------- ----------------------------- DATE--- -- BUILDING PERMIT ISSUED----------------- ---- -- - - -- ------------------------------------•-------- DATE l Alterations ---------------------------------- and/or recommendations________ _______________________________________ --------- - ------ - -- ------------- •---- ----- +r ----------------- --- - ------ ---------------- ------------ -- ------------------------------ - -------------------- ---------------- -------- -------------------------------- FINAL INSPECTION 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 ES-7-2M 10-52 Revised W-2100 ,