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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) /.l;"� pca s Date Issued --------------14------_ 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 0dn ce No. 544. JOB ADDRESS AND LOCATION-_.-------- I��S w Owner's Name-----------•---------- -- ----- -- -- Phone---- Address ---------------------------------•-------------------------------------------------- ------------------------------------------------- Contractor's Name - -J - ----------------------------- Phone------------------------_ - --------- _3 Installation will serve: Residence ❑ Apartment House ❑ Commercial [:1 Trailer Court E] Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ---------------------_.-----_ Water Supply: Public system , PP Y� uy ❑ Community 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 ❑ W Previous Application Made: Yes [) No ❑ New Construction: Yes ❑ No ❑ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) j S t'c Tanks,— Distance from nearest well--___---- Distance from foundation--------------_.--.Material-------------------------------------------------- No. ---__..---._-.-_.-_----._--_.- _- # ------ o. o compartments--------------------- ----Size-•-----•----------- ------------Liquid depth---------------------- ---Capacity------- I Disposal Field Distance from nearesfiwell.----Sar____-._Distance from foundation----_„.IDI......Distance to nearest loft line---.--'�-��_-- Number of lines-------------------I- --------------Length of each line------------4a--�--- -----Width-of trench------------ �� -` ----.----- r Type or filter material----------- -------Depth of filter material----.__- '*........Total length----------- / .�' SeePage Pit: Distance to nearest well----------------------Distance from foundation-----.-------------Distance to nearest lot line-----__---.--__- �( 3 6 Number of pi#s--------r-------------Lining material----------------------.Size: Diameter-------------- --------Depth----------- ---- Cesspool. Distance from nearest well--------------- -Distance from foundation___-_-.-__... ------Lining material-----------_-------------------------- F] Size: Diameter-------- -----------------------------Depth-------------- ------------------------------ ------Liquid Capacity---------------------------gals. r n Privy: Distance from nearest well-----------------------------------------------Distance from nearest buiidin v ti g ----- ❑ Distance to nearest lot line...... ----------------- •---------------------- •------------------ Remode#ing and/or repairing (describe):_@.__-- � ------ L�" � ------------ ----------- - 1 `t --------------------------------------------0------------•--------------------------------------------------------------------------------•-•-------------------------------------------------------- I 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)_..-i{/--. ----.�Of�. ------------ /� ---- (Owner and/or Contractor) 1.. ------------- ,"rT----------------------------------------------(Title)--------------------------------------------------------------- (Plot t plan, showing size location of system in relation to wells, buildings, etc., can be placed on reverse side). a. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- - REVIEWED BY ------ _ --------------- ---------------------- DATE--------_--•----- -- --- - ------ ---------------- DATE BUILDING PERMIT ISSUED - --- -- ----------- DATE ------ ------- - ----- - - - ------ -------------------- Alterations and/or recommendation ._-_------..-_--- --------------------------------- f ----- ----------------------------------------- -- l G( �- ------------&---------------- ---------------------- FINAL INSPECTION BY ........... (t ° f �t?-_. 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 r0-52 Revised W-2100