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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �, c Date Issued __-_-_ 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 Ordina e No. 549. � , 1 pOS- f�f fS r 4 t f +► �' J' -------- -----1� '=-�---- -- `-JOB ADDRESS AND L CATION---- - - �-- ~�7 �-^-- --------- ---- - - Phone Owner's Name -!-�1_--C-�'`"� Lt�'t � 1 -a-------- -- --- - -`-``�--------- - -----------------------------------------------------•---------------�------- Address ------- --- -- 0r---- '� _ : Contractor's Name-----------[A-_o_14.< .,��.------------ ----------------------------------------- ------------------------------ -Phone.------------------------- I Installation will serve: Residence gj-'-A-partment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other I' Number of living units: .-_-- Number of beclrooms�z�--- Number of baths ----l-_ Lot size --____-----_-----_ I Water Supply: Public system E] Community system F1 Private '.baths to Water Table .50__ ft. �l Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No [ TYPE OF INSTALLATION AND SPECIFICATIONS: (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------------------------- Capacity----------------------- �} Disposal Field: Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line----.--..-- ❑ Number of lines-----------------------------------Length of each line------------------------------Width oftrench---------------------.-------------. Type of filter material-------------- ------- Depth of filter material-----------------------Total length.--------------------------.-------------- Seepage Pit: Distance to nearest welL__ -----------------Distance from foundation____+_r __.Distanc ,to nearest lot line--Fr--�---. Number of pits---------J----------Lining material_ �Ll.h.�'_r_ Size: Diameter____ �-__Depth----_'2-_�_-_____-_______- i Cesspool: Distance from nearest well-----------------Distance from foundation--__-___-----------.Lining material____-----_---___-----____---____-_----. E] Size: Diameter--------------------------------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. . i . Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------_-__---____---__----. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- RemQdelin and/or repairing (a]escribe]:________ __g_ _`__"`.___ -_At I r� T� -�'�� !lJ�i I` �' -' f '' �' -------------------------------- - ------------------------- - h ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ __ ` 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 re, ulations of the_ an,Joaquin Local Health District. i�r Si ned --------------- / ,�ifi - - ---��`./--- ---------------------------------- ---------------(Owner and/or Contractor):_.:.. -By:_---------------------=----------------------- ---------------------------------------------------------------------------(Title)----------------------------------------------------------------- ' (Plot phn, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). } FOR DEPARTMENT USE ONLY ' APPLICAT'7N ACCEPTED BY------- ---- ------------- DATE- - " � "^"". REVIEWED;Y--------------------------------------------------------- ------------------------------------------------------------ - DATE ----------------------- IBUILDING Pti??MIT ISSUED------------------------------------------------------------------------------- ---------------------"DATE----------------------------------- Alterations angor recommendations--------------------------- -------------------_.____ k - V ------------------------ --------------------------------------------------------.----------------------------------------------------------------------------------------------------------------_---__---.--___-__----- -------------------------------- -------.------------ ------------------------------ .___ ---------------------------------------------------------------------- ---------------------------------___-___-__-_________-___ --------------- - ----------- -_.-_.-_---.----- t---- -------- ----- -- --- -- FINAL INSPECTlO, -�`��•-"' �—��_ Y:. ------------------------ a e ..- r SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Str. 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 9_6l Revised W-21b _