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t � APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) L�l l d Date Issued _ X1-,7_-/_-4 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 rdinance No. 549. JOB ADDRESS AMC' LOCATION•--Z_ -- - - �______ ---------------------------------------------- Owner's Name Phone ------------ - -----•---------------•----------------- �j _ Address . 'fit = -------------•----------------•--------------•----------------------------------•------------------------------- Contractor's Name-------------------------- ---------------------------- Phone. Installation will serve: Residence Apartment House L] Commercial L] Trailer Court L] Motel E] Other �] Number of living units: � mmunify --_ umber of bedrooms -,Z-- Number of baths __L --- Lot sizeWater Supply: Public system system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑- Gravel ❑ Sandy LClay Loam E] Clay El Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yesoam No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public swer is available within 200 feet.) r Septic ank: Distance from nearest well_- Dista fro fro ffou tion----1__ ----__.MateI--- L1_ - - - ----------- ------ --- No. of compartments------------ -- -----r-Size__- - -- _--Liquid de ;h_--- at-e-- -----------Capacity._- -� --- Dispos Field: Distance from nearest w II- -_01�----Distance from foundation- i_ Distance to nearest lot lin Number of lines___________ _ _ Length of each line-------- Width of trench----- - - ______________ 1 Type of filter materia - -------- -- Depth of filter material_------_ -- -- ----_Total length___----L t_ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Sze: Diameter------------------------Depth--------------------------------- 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)------------------------- -------------------------------------••--------------------•-------------------------------------------------------------------------•--•------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. (Signed)-_Ok7nw_- -------------------------------------------------------•----------------------(Owner and/or Contractor) By------------------------------------------------------------------- -- ----------------------------------------------------- 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---------------------------------- ---- ------------------- ----------------------------------------------------------- DATE------ BUILDING PERMIT ISSUED--------------- - ----------------------------------------------------------------------- DATE--------- - Alterations and/or recommendations:---------------------- ------------------------ ------------•--------------------------------------- ------------------------------------------- -------------------------------------------------------------------------------------------------------•----------------------------------------••----- -----------•-------------------------------------------- ------------------------ ------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------•----------•-------------------•---------------------------------------- -------------- ---------- FINAL INSPECTION BY--------------------------------------------------- ------------ 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 ES-9-2M 8-51 Revised W-2100