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APPLICATION FOR SANITATION PERMIT Permit No. =1______`____v__ (Complete in Duplicate) Date Issued 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 compli rice with ounty Ordinance No. 549NaLf r �oI si JOS ADDRESS AND LOCATION =,n"—'.j a ------- ------ ----} G,D r- j--r Owner's Name------------�-----&-------- 4------ • Phone p J�/y - - -------- Address.------. -- 8 I f Contractor's Name � --------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�____ Number of bedrooms .- Number of baths ---/--- Lot size _________1__Z?_x__��____________________ Water Supply: Public system E] Community system El Private VDepth to Water Table� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay Loam ❑ Clay ❑ Adobe2//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.) Ma �Septic rank: Distance from nearest well____�V-----Distance from foundation------- i -_------- eTeJe--------------+ No. of compartments----------- q _ -Ca acit ovtl &60� _______Size__C✓ __ _ ? _ _Li q. -Liquid de th_______ ---- ------ Dispos Field: Distance from nearest well__-_5_0____.Distance from foundation_______--------Distance to nearest lot line-------5______ Number of lines------------- __ Length of each line___'_�0__�`_�-�----width of french--_-_____r�_ ---------______ � It Type of filter material__t_s.-___rj2(k__Depth of filter material___.J_8------------Total length______1_2D.......................... Seepage Pit: Distance to nearest welt----------------------Distance from foundation--------------------Distance to nearest lot line------------------ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h--------------------------------- `r 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 lire------------------ ---------:------------------------------------------------------------------------------------------------------------------ Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- ---•.---------------------------------------------------------------------------------------- -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate law and rules and re ulatjp,,r 'of a Safi Joaquin Local Health District. (Signed)------ ---------- - z----�� -------------------»----------------------------------------(Owner and/or Contractor) By ---------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot pla , 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-------_(y � - ------_---------- ---------------- --- I REVIEWED BY--------------------------------------- ------------------------------------------------------------------•DATE----- ----------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE- Alterations and/or recom rations: ;"/ X------------ -------r _ ---------- -------------------------------- jh= ---- - ----------4-11------ ------------------ --- ----- - �/- : .-- ------------------------ -_-------------------------- ------ ----- ---------- f� ----------- -------- - --------------- -------------------------------------------------------------------------------- � ---- FINALINSPECTIdf� _ - - ---------------------------------- Date-------------------------------------------------------------------------------- dN0AQU6 LO0A L 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