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APPLICATION FOR SANITATION PERMIT Permit No. ____-_3_/.5__.. (Complete in Duplicate) 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 Ordinance 4No. 544 �r JOB ADDRESS AND LOCATION___-- --- --- -------- ---•-•---- - ----------•------------------ - ---- Owner's Name-- o �rO � --------------------------------------------------------------- - ---------------------------- ------ Phone---------------------------•-------- Address------ ------- ------------.- ------ ---------------------------------------------------------------------------------------------------P--h--o--n-e----•-------------------G-- ------------ Contractor's Name....� d-- ------------------------------------------------------------------- - -------------- ----------------------------- Installation ----------- Installation will serve: Residence A---17artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l____ Number of bedrooms __- Number of baths -1---- Lot size ------x__1 r'___________________ Water Supply: Public system 14_ immunity system ❑ Private ❑ Depth to Water Table SP ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ M Previous Application Made: Yes ❑ No ew Construction: Yes ❑ No IS— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: r Distance from,,nearest well-----------7------ _;-_--_- ----_Distance from foundation___________________Materidl--------------------------------------------------- No. '_______:___-___---___________--_____--_____.No. of compartments--------- ------------Size----- --------------------------Liquid depth--------------------------Capacity-------------------- ispo a, ' Id: Distance from nearest well__-_–. _- -_.-._Distance from foundation--------------------Distance to nearest lot line____.___..._..... A 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 f om fo dation___. li�____.Distance to neares o r N------De th 'Z [4�� Number of pits______ _____________Lining material--- TA Diameter_rc .--.-._ p Cesspool: Distance from nearest well----------------- from foundation....----------------Lining material-------------------------------_ ❑ Size: Diameter---- ------------- ------- ----------Depth--------------------------------- -----------------Liquid Capacity-...------------------------gals. Privy: Distance from nearest well.------------------------------------------------Distance from nearest building----------------__--__---_-__-__-_____-_- n� F Distance to nearest lot line - --------------------------•------ - ---------__------------------- �l Remodelingand/or repairing-(describe):----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------••--------- ----------------------------------.---•------•------- -------------------------------------------------------------------------------------------•-••---------------------------------------- ► --------------------------------------- -•---------_. I----------------•--------------------------------------------------------------- ------------ ----------------•------------------•-------------------------------- -------------------------------- ----------------•--------------------------------•-••----------------------•-----------------------•--------•--- -------•-•-----------•---------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, Sta laws, nd rules and re uta+ions of the San Joaquin Local Health District. [Signed] -- ... -- • •- - (��.Contractor] y BY=---�-- 42—,rw ---------------(Title)------------------ ------------------------------------------- (Plot plan, showing size of lot, location of'system in relation to wells, buildings, etc., can be placed on reverse side). S FOR DEPARTMENT USE ONLY 3 APPLICATION ACCEPTED BY ------ ----- DATE ._.... REVIEWED BY--------------------------- ------------------------- - ----------------- -------- -------- ------------------------- DATE ATE--------�: -A-•----••---------------------- -- ---- -- BUILDING PERMIT ISSUED---------------------------------- DATE----------- x ------------ Alterationsand/or recommendations------------------_-- �----------- -----_------------------------(---------------------------- ----------•-•-------------------------------- j i-- - ---------------------- ------------------- ------------ - ------- ) - '� l ..... ... ... -------------------------------------------------- - -- -- -- ----- -- - -- ----------------------------- ------•---- FINALINSPECTION BY:------ -------- -------1JE--------------------- Date------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130.,South American Street 300-Wesf Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 4 Es-5-2M� to 'e.TwoP❑ tz-sa