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APPLICATION FOR SANITATION PERMIT Permit No,,?- 's p_ (Complete in Duplicate) Date Issued - � 6 � A pia ion is hereby made o the San Joaquin Local Health District for a permit to construct and install the work herein described. Po This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION a , ----------------------------------- ------- --- PhoneOwner`s Name---------- - ------- •--------------------------------------------- - -Address- ------------- t -- ..... Contractor's Name______________k"Ale � --.--------------------------------------------------------- -------------------------------------------- Phone----------------------------------- i Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Ili Number of living unifs,: I--- Number of bedrooms _ ^' --- Number of baths I--- Lot size ----� --------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. 11 x Character of soil to a dept of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam ElClay E] Adobe Hardpan E] Previous Application MadegYes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION SAND SPECIFICATIONS: (No septic tank or c.11. of permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_?��Distance from foundation---/__4_._____-_--Material_l ...-o Z�------- N No of compartments._____ C' --------Liquid dth ep __.ZA---------____-Ca acct ------------Size------ -�-- - r- - -- P Y---�--------------- Disposal Field: Distance from from nearest well- _.Distance from foundatio __1_Q__----------Distance to nearest lot liee__lS�___.. ` Number of lines5. ------- _________Length of each line_____ ___--�j F, O Width of trench_i -Sf__________-----__-_-- Type of filter material___�ta- _--______Depth of filter material___ _Q______________Total length------ --- _�___-._____________________ See* Distance ts______________________Linin material______--_ foundation---_____________--_.Distance to nearest lot line_____-----_______ � 171- Pit: Nubd of nearest well-____________ _g Distance from------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distan�h from nearest well-________________Distance from foundation------------------- Lining material---_______________________----.-_____: ❑ Size: Diameter--------------------- ----------------Depth----------=-----------------------------------------Liquid Capacity----------------------------gals. Privy: Distan I0e from-nearest well-----------------------------------------=-------Distance from nearest building----------------------------------------- �- ❑ Distance to nearest lot line------------------ - ----------------------- ----------------------------------------------------------------------------------------------- �ip ---------------•-------------------- Remodeling and/or repairi (describe)--------------------------------------------------------------------------------------------------------- --------------------------------------- ------------------------•-• --------------------------------- ---------------------------- ��--------------------------------------------------------------------------------•------------------------------------------------------------------------------------------- _Il I hereby certify that hihave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s,'and rules and r ulations of the San Joaquin Local Health District. (Signed)--------- . --- • ---- By: . !I p ----------- - ------------------ --------- --------(Owner and/or Contractor) By:-----------•---------------lu.::.--- --------------------------------- ----------------------------------------------------------(Title)------------------ -------------------------------------------- (Piot plan, showing size of to t, location of system in relation to wells, buildings, etc., can be placed on reverse side). ll 7 FOR DEPARTMENT USE ONLY kAPPLICATION ACCEPTE© BY----------=------- ------------------------------ DATE---------------------------------------------------------- REVIEWED BY !IF�I --------------- -------- DATE-- �j- ,- '------•------ BUILDING PERMIT ISSUED ........... DATE Alterationsand/or recom de ndations:------- -------- --------------------------- ------------------------------------- ----------------------- -----------------------•------------------- ------------------------------------------- `---- ------------------•----------------------------------------------------------------------------------------------------------------------------. -- ----------------------------------- -------------------------------------------------- --------------------------------------------------------------------------------- ------------------------------ - ,. ------------------------------------ ------------------------ - FINAL INSPECTION BY:-------- -- ------- ----- -------- ---------------- Date---------r /8�/ � ---------------------- I # ISAN JOAQUIN LOCAL HEALTH DISTRICT a 130 South American Street 3D0 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I I Lodi, California ; Manteca, California Tracy, California ES-9-2M 8-51 Revised W=4100 ~