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APPLICATION FOR SANITATION PERMIT Permit No. / - (Complete in Duplicate] ate DDate ApplicaFion is hereby made to the San Joaquin Local Health District for a permit t construc nd install the work herein described. This application is made in compliance with County Ordinance No. 549 1 47 JOB ADDRESS AND LOCATION____ Ad A..-- -1- � � Owner's Name------------ ---------------- Phone-------------------------- •-------- Address------------------ Contractor's Name. Q d` ' r �r�_. Phone / '�F=f Installation will serve: Residence [A�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___�___ N er of bedrooms _*Z_ Number of baths ___f_ Lot size ____- __ __ _ ------------- Water Supply: Public s stem` Communit s stem Private Depth to Water Table -_0 ft. � PP y' Y Y Y ❑ ❑ P Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ lay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ .No Ekl ew Construction: Yes to ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or cesspool permitted if public sewer is available within 200 feet.) O Septic Ta k: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- No. of compartments----------------- Size----. --------------------------Liquid�depth--------------------------Capacity----------------------- Disposal Fi Distance from neares well_____.___._ _D_.Distance from foundation _� Distance to nearest lot line._�4r_ ._ Number of lines_________ _ ......_/-Length of each line------ -- Width of trench_______, _'_ ---------------- ��- y Type of filter material- _ ._ Depth of filter -Material----1_�______f dotal length-------�__�---------------f See^pa,ge Pit,.-- Distance to nearest well-�D-_ Distance fr m,,f-ou�,dation.��__.._..D• to ce.to nearest lot line-Rd_____ L� Number of pits__.( n ------Lining material--- rSize: Diameter__._ -----------Depth----�s�-�_____.___.____ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______...____.._____---- ____----_. [] Size: Diameter--------------------------•------------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. Privy:. Distance from nearest well-------------------------------------------------Distance from nearesf building------------------------------------------ El Distance-to nearest lot line-------------------------------- ----------- -- -------" ------------------------------------------------------------- Remodeling and/or repairing {describe:--- ._ - ---------- ------ -------------_--� -------- ---- ----------------- - ...- -� - --- ----------------- --- ------Z---- ___ _ - _.1L_ - 41 ___________________ ______..___ ________________________._____________________________--.-_________-______._----------_._-____ ________________________________________________________________________________ ___ I'hereby certifyahat.l have prepared this application and that the ork will be done in accordance with San Joaquin County ordinances, Stafe' s;an rules and regula ions of the San Joaquin cal Health Dis+ric+. * l f� t`'� ------(Owns d/or Coa actor] (Signed)-------•-- ��' t )kj By:--- ------ --- - --------------------------- ----------------------------(Title)------- (Plot plan, s o�g sire of lot, location of system in relation to wells, buildings, etc., can-be placed on reverse side). S s 4 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY...............---•----------------- -- -------------------------------------------------- DATE------ ---tt----- �-�S - REVIEWED BY -------------------.------------------- ----------------- - ------------ - -•-•-------------------- DATE---------- -----�-----------------�-------- --- ------------------ BUILDING-PERMIT ISSUED------------------------------------------------------------------------------------------------- DATE------------------------------------------------ - - Alterations and/or recommendations--------------------------------------- -------------_. ---------------------------------------------•---------•----------••--------------------- ----------- -------------------------------------------------------------------------------------------------••---------------------------------- ----------------------------------------------------------------------------------- ---------- ---=----------------------- - - ------------- ------------------ ------------- - ------------------------------------------------------------------------- -------- ------------------------------ FINAL INSPECTION BY------------- ----------VA�e � Date- .-----------1-I------------ --- --------------------------------------------- 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 ; Revised W-21oo