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APPLICATION FOR SANITATION PERMIT Permit No. 1� (Complete in Duplicate) Date Issued/..a. :,/`.5_e Applica-lion 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. 4 JOB ADDRESS AND LOCATION.-B-4 -----•-------•------------------------------------------------------------------ Owner's Name ' ' ---- ------------------- Phone------------------------ Address_.._..... /......---•_ .-------•-•---• •--------------------------------•------------•-•-•----•-••-•--------------•------------ -------- / Contractor's Name.-. ----Ll-`--- I -•-----------•------ Phone//' .�------'-�--- Installation will serve: Residence �partment mouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [❑ Number of living units: __j__-_ Number of bedrooms __-Le Number of baths ___k_ Lot size .-_ lel__ -___L _--_________-__--_______ Y ' Water Supply: Public system -Community system ❑ Private ❑ Depth to Water Table ________ ft. Char cter of soil to a depth of 3 feet: i Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam t] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 6— New Construction: Yes ❑ No W _ � 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._-_-____________ 'w Number of lines- -----------------'-----------Length of each line-----------------_-----------.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: - 'Distance to nearest well_-_ - Distance from fou da+ion___.. A �'!nr_�'"<--'_ , 11 �6_....___Distance to nearest lot line_.___r�l�_�__ [ - Number of pits__;-----/_--_.,____-Lining material._-13.444./k Size: Diameter._{�y3_'__e..____Depth___'.7._ Cesspool: Distance from nearest well------------------Distance from foundation----------------------Lining material__.----____________.____._____-____-_ ❑ Size: Diameter ;' Depth •-------• - = -----------------------------Liquid Capacity- - -----------------------gals. _ ti� • - _. _ ._ .,.�. --fes ti-.�- ;, •�:�� .. - - �- Privy:- Disf6nce�from nearest well------f---------------------------------------#1 Distance from nearest building_____________________ y__ ❑ --Distance to nearest lot line---------:--_--------_'_-_ 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. L (Signed)-•--• ---- -- ----=------------=--------- ------ p Contractor) By:.... _. ----------------------------------------••--------E--•--------(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 APPLICATION ACCEPTED BY = 1Y = DATE-------- REVIEWED BY 9 ,.-.. -------------- DATE----- ----------------- BUILDING PERMIT ISSUED_---•---•-• -•--------------------------------------------------------••------••--- ---------- DATE--------------------------------- Alterations and/or recommendations;----r---------------------------------------------------------------------------------------------------------------------..•----------------------------------- ---- . ----------------------------------------------------------------------•------------------------------------------ ----------------------------- --------------------------------------- ----------------------------------- --------------------------------------- ---------------------i-------- -----------------------------------------------------------------------------------------------------------------------•----•------------------ FINAL INSPECTION-BY:: --- -----1--- Date: r ! l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California M6nteca, California Tracy, California ES--9---2M : Revised W-2100