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f APPLICATION FOR SANITATION PERMIT Permit Nc4.�`^_._.S._ (Complete in Duplicate) Date Issued&__f_r�.u�'.+_ Applica{ion 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----- 4-----(] r�--- ---- �' �, Owner's Name------------ ..tJ-4 .- t l- '!'� �.t-� ------------------------------------------ Phone. 7- Address --------- ------------------------------------------------------ ------_ ----------------------------------------------- Contractor's Name_________________r Installation will serve: Residence W""A'partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ --- ------------r Number of living units: _._/___ Number of bedrooms __ _ �__�� Number of baths /___ Lot size ______- _"__-_;�,____• 0 f Water Supply: Public system eIommunity system ❑ Private ❑ Depth to Water-Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: septic tank or cesspool permitted if public sewer is available within 200 feet.) V` &(No T IF- Distance from nearest well-----------------Distance from foundation-------_------------Material______.______._____.________-------_.._______- 1 No. of compartments--------------------------Size-•------------------------------Liquid depth----------- --------------Capacity----------------- --- i posal F ca: Distance from nearest well_________________Distance from foundation.-------------------Distance to nearest lot line--------------_- � I�"' I Number of lines-----------------------------------Length of each line------------------------•-----Width of trench----------------_-------- ---------- Type of filter material________ __________I-----Depth of filter material----------------------- length------------------------____________..__-- Seepape Pit: Distance to nearest well__A �-----Distance fir foyndation----ll.. r..__..Distance to nearest lot line___f _® _____Linin material-- ------ ----------_ Size: Diameter_ - - De tn_.. _ _. ~ Number of pits g ------- p Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining 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)-----------------------------------------------------------Y--_--------------------••------•- -••---------------.._...---•---•--------------••-------- -------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------•--------.•------------------------------------- -------------------------------------------------------•-------------•--------•-----------------------`----------------------------------------------•--------- -----------------------------------------•--••--------------- ! hereby certify ave prepared this application aid that the work will be done in accordance with San Joaquin County ordinances, State la s, and rue and reg ations o. the San Joaquin Local Health District. (Signed)--- ----•---•-----------•--•-- --------------------------------------------=----------- -- -- -- A-r -- --------------'--- ----------------------- ontractor) By:---------------------------------------- -----..--------•-•----- ------------- -- -- -- ---- ---- , (Plot plan. showing size of lot, location of system in relatio wells, buildings, Ac., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ --_-- _ _ _ _ - _ DATE-=------------------------------------------------------ - -- - -- ----------------------- -- -- --- ---------- --- REVIEWEDBY-------------------------------`...�, -------- --------- - -- ------- ------------------------- 1-------- DATE--- ---------•---------------------------------------- BUILDINGPERMIT ISSUED.-...----------------------------- ---------------------•--------------------------------------------- DATE------:,,it------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- -------------------------------------•------------------•-•------------------------------------------------------------------------------------------------------------------------------•----------------------------------- --------------------------------------------------------------------------------------------------------------------------------•-•--•--------•---- ------------------------------------------------------------•------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- -------- -------------------------------------------------------- FINAL INSPECTION BY:.. =�: z S Date - ---- -- -�---- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American 'Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4-2M Revised W-2100