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APPLICATION FOR SANITATION PERMIT Permit No. ......... (Complete in Duplicate) t D Date Issued --------_ Application is hereby made to the:San Joaquin Local Health District for a permit to construct and install +he work herein described. This application is made in compliance with County Ordinance No. 549 JOB ADDRESS AND LOCATION_::_. _ _` _ _ ,___ ______ --- - - ----------------------------------------------- ,�w Owners Name A ----------------- Phone Address -- - --- ---------------- — Contractor's Name------ ---`---• -- --------� -- --- ---- ----------------------- Phone-- Y-d,6--��----e INV Installation will serve: Residence ❑ Apartment House ❑ Commer ial Trai r-Court Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ------ Number o at __ Lot size ________, 1. __ ___ -—-------------- Water Supply: Public systemr6�Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 f et: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 5�4ardpan ❑ Previous Application Made: Yes ❑ No A-`INew Construction: Yes *'<o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public se r is available within 200 feet.) Septic T nk: Distance from nearest well_ Vop- istance from foundation__.1.0---_� M t I � _ ___ ______- rze_ � ----------- d th__ __ a-r------Capacity---- ---o. of compartments-------�------- ' Liqui Disposal eld: Distance from nearest well.+ istance fxroopdtion___d ______Dist to nearest lot line__-.- _�___ Number of lines--_______________- ---Length of each line------40-0-�___ Width of trench- •-. �-------------- Type � � T e of filter mraterial ._. De th of filter material____/_ T Total len th_____-_ S� _ Seepa it: Distance -to nearest well-.- _-_. _Distance from f ndation____to..._Distance to nearest lot line_____l�_____ Number of pits i__-__I_____________Lining material__4 -_Size: Diameter_____ �__.___ v 1 ----.Depth---�-�------�------------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- material------------------------------------.. ❑ Size: Diameter. ------Depth-------•--------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____________________-____.-:______.____.. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):- ------ ----------••-------•--------------------------------------- -----------------------------�----•-----f� �.5��.� -------•------------------•----•---•---•-----------------•------•----------•-------------------••--------------------------•- ------ --------------------------------•-----••----•------- -•----------------•--------------------------------------------•-----------•-•-•--------------- -------------- ----•-------------------------- ----------...• ---------------------------------------•-------------•-------------------------------------------------------------------------------------------------- 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. S anedw --___. Owner and �.._...- �•��1 /o Contractor By:..... L--- - 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-------- ^_ DATE--------------------- REVIEWED BY----------------------- / f DATE--- BUILDING PERMIT ISSUED------- ------ DATE Alterations and/or recommendations:__ __.---------- --------------- +.• i _ _________ ___ __________________________-----_-_______________ -- ------- -�� `S *' V_ _d�ci. - _, 4 v "t r ±..a ' ° sr �L -----A ---------------------------------------------- - --- ------ ------------------ ,,,tr�,. ---- --- ---------------------------- I ------------------------------------ ------------------------------------ -------------------------------------- ------------------ ��. FINAL INSPECTION BY: Date--- .---- `r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street .4 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California t ES-9-2M 8-51 Revised W-2100