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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued _-2 Ael x' 1 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------- - ' , p Owner's Name ! ! ------------------------------------------- 56.1. ----------------------------------------- Phone e Address �? 1 Contractor's Name_____ _ _ Installation will serve: Residence 2000AOpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __{--- Number of bedrooms --,I- Number of baths ___ _ Lot size _______4 01--_�___ ----- ------------ Water Supply: Public system j;--community system' ,'-_Priva.te ❑ ,Depth to Water Table __,_____ ft. �r 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.) Ir...� , . . Septic Tank: Distance from nearest well_-_________ _Distance from� founm.dation____________________Material____-_-___-__________________.-______________. I ❑IC No. of compartments--------- ---�- -------Size------------------ --------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well__A` i � stance from foundation'-/ to nearest lot line__________ Q�, Number of lines_________________ Length of each line-_-__. 0____ _______ Width of-trench__--------- Type of ?4 of filter material_-.,$ ) Depth of filter material___1_�_- ------Total length__-------IP_0----------------- ------ Seepage Pit: Distance to nearest well------.___i-_________Distance from foundation_'----------------.Distance to nearest lot line______--_-------_ ❑ Number of pits-----------------------Lining material-----------------------Size: Diameter------------------------Depth------------------------------------------ Cesspool: Distance Distance from nearest well__._____ _Distance from foundation-------------------Lining material__________________-___-_____________- ❑ Size: Diameter--------------------------------------Depth-----------------------------------------------------Liquid Capacity,---------------------------gals. Privy: Distance from nearest well------------------I------------------------------Distance from nearest building------------------------._---____________- ❑ Distance to nearest lot line X ------------------------------- �- •-------------------- ---- Remodeling and/or repairing (describe):---------- .- -----------------------------------------------------------•----= •--------------------•-------------- e. t --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that:l 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. (Signed) �/ - _ - + p p �_--� '" ---- [Ow er and/.<or Contractor) / ,.• --- By:-------- ��-�-�----L_ Z_4 --------------------`-----------------------------------------------------(rt ---- = ' Ie)_ (Plot plan, showing size of lot, location of system in relation .to wells.,buildings, efc., can be placed on reverse side). 1 r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '---------------------------------------------- DATE-_---- ----------------------------------------------------- REVIEWED BY--------------- ------------------- ¢ "-'- DATI �' BUILDING PERMIT ISSUED----- DATE ''----------------------------------------- Alterations and/or recommendations:_ ---- t t -w + --------------------------------------------------------------------------------------------- ------------------- ------------------------- ---------------------------------•---------`----`---------------------------------------------------------------------- ---------------------------•--------- --------------------------------------- -------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- -------:--------------------------------------------- ---------------------- ------•--- I FINAL INSPECTION BY:-------------- I__VI Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 13.2 Sycamore Street 814 North "C" Street Stockton, California - Lodi, California Manteca, California Tracy, California ES---9-2M 8-51 Revised W-2100