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APPLICATION FOR SANITATION PERMIT Permit No. 40-------- } tv f (Complete in Duplicate) Date Issued24 ll --- 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 o. 549. 1 JOB ADDRESS AND LOrrCATION___-, -- ----------- -_� -------- Owner's Name--------- -l-,ST�lr..d--------- - Phone Address--------------------------------- - ....... ----- ------------------------------------------------------ Contractor's Name-------------------------- ------ Phone----------------------------------- - ------- ---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ---1--- Number of bedrooms `_' _rNumber of baths ---)---- Lot size ----_ w�' ---- Water Supply: Public system ❑ Community system ❑ Privateepth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe&L'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----------------- r ! L Disposal Field: Distance from nearest well_ Distance from foundation____-0•4--------Distance to-nearest lot line-_-.t6---_--_. Number of lines----------- } _-}__-------------Length of each line_____j__4---0-----------.Width of french-------y.----------------------- Type of filter material.f- --1-0w-k".Depth of filter material--:----1-P'-------Total length----------1-_j'_-a7_--____---___--._ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--------.----_--_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-_-------------_-_----____--_--____-_. �] Size: Diameter--------------------------------------Qepth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------- ---Distance from nearest building_-_--_--_--_--------_____-.__--_--------. ' ❑ Distance to nearest lot line-------------------------------------------------------------ti------------------------------------------------------•---------------------- Remodeling and/or repairing (descrii�e�: »-f------.r- _ '�"--.�---------- ------- -•----_----------------- -------------- ' .P -•------------------------------------------------•------------------------------- { ---------------------••-------------•---------•---------•---------------------•--------------------------------•----------------------------------------------- ------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- 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 a d regulatio f A San Jo quin Local Health District. Owner and/or Contractor {Signed}-- - �--------- - -' -------- - . --- { / } 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 It X APPLICATION ACCEPTED BY------------ -- --------------- -- •-- DATE__-__ ,.�'� '7 ---------------- REVIEWED BY-------------------------------------- DATE--- ------ = v------------------------ BUILDING -------------------- -- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- ------------------------ - -------------------------------------------------------- DATE---- ----------------------------------------------------- . .. Alterationsand/or recommendations----------------------------------------- ----- ---------------------------------------------------------------------------------------------------=----------- ---------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------- ----•----------- --------------------------- � _----------------- FINAL INSPECTION BY-------------�- �5 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfroat 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100