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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) y bate Issued __..�_--- ___ _S� Applica4-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 LO 'ATION�_' �_. - - ------ ---------------------'-Y------ =-'-"--- ---- ---- --------------------------------------------------- Owner's Na -- - -*------------------------------ ------------ i------------------------ ------------------------------------------- Phone--------------------------------------------- Address- ---. ••-•,...... Contractor's Name.------- --------•--- -----------•-----------------------------------------------------------------------•----------------•--- Phone-----•-•----------------•- •------ t Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: 11�Number of bedrooms __&_ Number baths J---- Lot size -7�_._______________________________-- ............ Water Supply: Public.system ❑ Community system ❑._Private DepthJo Water Table -------- ft. Character of soil to a depth of;3 feet: Sand ❑ Gravel ❑ Sandy Loam Loam ❑ Clay ❑ Adobe 2"'Hardpan ❑ Previous Application Made: Yes ❑ No �e New Construction: Yes Q' No ❑ TYPE'OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if ublic sewe)is available within 200 feet' ptic �ank::, ._�;; Distance from -rest well_____..... isfianc-.':fro .fou �tion��(!_______________Mate i _ ___ ___ ___.____._____ _ ____ _ LI No. of compartments -- i Liquid depth---- --- �—� S e r --Capacity -- ---- Disposal , Dis osal Field: Distance from nearest well.�_n --.. istance from foundation._ _._ Distance to nearest lot lin t_ Number of lines----------- .. . --------- ength of each kine_____.___._ F Width of french........... .. tl Type of filter materi '�i4-- ----_ pth of filter material---------- _ -----Total lengfih--------------,---- ____._ { --•-- Seepage Pit: Distance to nearest well___ - _ .T.i_Diatance from foundation=.7:---------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material--l-------------------Size: Diameter----------------:-----.Deptn--------------------------------- Cesspool: Distance from nearest well _--__----------Distance from foundation__________________ Lining material------------------------------------- .:-+.❑ -�: -.. _.Size: Diameter-. _ e .T_De�thr_RT. ---. _W__— ,-----------._l,iquid.Capacity----------------------------ga-•• _ Privy: Distance from nearest well .............`,.___-_- _._--�- ----_-__Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-------- - ----------------- •--------------- - ----------------. -------------------------------------------------------------------- Remode a g an /or r•pairing [dost die}:_...___ 1 Y --C -n t =~=e ------------------------------ --------------------------------------•----------------- - ---------------------------------------- ------------------------------------------ �_ ----------------------------------------------- ------------------------------------------------------------------------------------------------------------------ ` I hereby certify that I have prepared this application and diet,the work will be done in accordance with San Joaquin County ordinances, Stat laws attd rules and re ulationt of the San Joaquin Local Health District. S B . :Si ned - P ------- ------(Owner and/or Contractor) y:.-_ { ---------- (Title) -- (Plot plan„sfiowing size of lot, I . tion of system in relation to wells, buildings,.efc., can be placed on reverse side). FOR DEPARTMENT _SE ON '-A RTLY APPLICATION ACCEPTED BY _ _ DATE_--------------------------------------------------- REVIEWEDBY . . ---------------------------------------- ------------ DATE--- --------------------------------------------------- BUILDINGPERMIT ISSUED------- ------------------ -------- ---------------------------------%----------------• DATE--------- - - 4 Alterations and/or recommendations------- ---------- �{ -------------------------•----•--------------------•----------------- - ----------------------------”----_--• -------------- --------------•---•-------------------------------------------------------------- -----•-------------------------------- - ------ - - ----- - 1 FINAL INSPI CTION Y:: ----------• Date .......(P------ ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E51-9-21A 145446 ATWCUD 12-54