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�y h APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued Applica4ion 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. zq_l� ------------ cPhon/ =JOB ADDRESS AND LOCATION Owner's Name------•--.� ----- --------------------- •---------- - --4----- - ......... -------------------------------------------------------------- - Phone.. Contractor's Name-.-- ---------------------•- Installation r j will serve: Residence House ❑ Commercial ❑ Trailer Court"❑ Motel ❑ Other ❑ r Number of living units: /----Number of bedrooms .-_-,2-Number of baths _,-_. Lot size ------- ----------- ---------- Water supply:- Publics stem Communit s stem Private Depth to"Wa#er.Tablez Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe Ell Hardpan E] Previous Application.Made: Yes El No�New Construction: Yes ❑ -Ne�R, 1. TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or:cesspool permitted if public sewer is.available within.200 feet.) Septic Tank: D-s ca from nearest well-----------------Distance from foundation-------------------.Material------------------------------------------------ - ❑ �_ , ompartments------------ ------------rSize-----•------------------------ Liquid depth-----------------=------- Capacity---------- -------=--- s Disposal Field: from nearest well__,jef? D'.stance from foundation---r.�Q_ ,"_.Distance to nearest lot I ne__-------- .�_" r / „Number of lines---------1______ _______ _ Length of each line________ Width of trench.__._odI_ _ o 4Z- -- ------ e A of filter material_=_,f_ 'l Tofal len __.. .y7------_-_-----_- : Type of filter matenal_-_l_�______�� p .-- --- � -- ---- length _ g s ' ' " Distance from found tion_____ Seepage Pit ` Distance to nearest'well_-_, _,. `��_�__.Distance to nearest lot line----- -----------_Linin material----P-0--CICize: Diameter.------; _�_`1Dept'n---- Ste- ------ Number of pits___._-� g Cesspool: Distance from nearest well-------------- Distance from foundation---------- -------Lining material_-_-_____________.___._____________ C ❑ Size: Diameter----- -`-------------------- =-------Dept h----------------------------------------------------Liquid Capacity-----------------------------gals. PrivDistance from neatest well--A--------------------------------------------�------------------------------- - -------Distance from nearest building-----------.------------------------- -- , Y ' Distance-to nearest lot line---------_--------------------------- -------- ---------------------------------------------- � -------------=------- Remodeling and/or repairing (describe):----------------- - --------------------------•-----------•--------••-•--------;----------•----•--•---------------------------------------- t .` --------------------- I --------1--------------------------- •----------------•-•--------- I ---••---------------------••--------------------------------------------- ----------------------------------------------------------------•---------_------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfate-laws;: and rules and regulations of the San Joaquin Local Health District. r and/or Contractor (Signed ------ -- ------------------------------------------------------ BY. ------- --------------(Title)------------- 7---------------------------- -------;------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). s � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------5 ------------ DATEv q REVIEWEDBY------------ ° -- -- ------------------------------------------------------ DATE------ ----- "F ` BUILDING PERMIT ISSUED------------=--------=------------- ? = - DATE.. - -•); Alterations and/or-recommendations:---------------------- ---------------------------------------•------- ---------------••---------\ ------------------------- - 4' -_ -------••------s-'--- -- -r---------------`-----_. -----....... -------------- --•------ -11--%"---------- -------•-- FINAL INSPECTION BY:.-`-_ ' - --------- _ _�....D t SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100. __