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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 3 Date Issued Applica+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 o. 549. � � et.. 9..1- -&Vvw ,o 0, 410 S7• ` r JOB ADDRESS AND �+LOCATION.____rX.___ � -- ------- -----------/ Owner's Name ----•-�---t_..L---•---.�/!�C�----------------------------------•--------------------- ------------------------------------------.. Phone-------------------------------- Address----- ---- -- ---------- ------------------------------------------------------------- Contractor's Name-- 0. -----------------------------------------------•------------------------------------------------ PhoneAb�_�t_.. Installation will serve: Residence 25--,;Tpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I___ Number of bedrooms _ Number of baths -1----- Lot size __'�4Y�1_x----Q yZnV___________________ Water Supply: Public system ❑ Community system ❑ Private 94--ft,pth to Water Table fff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loamay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No [�--PteW onstruction: Yes ❑ No f�j- — _ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Qnk: Distance from nearest well__________________Distance from foundation________________Materiial_____.________________________..__-___________- No. of compartments--------------------------Size--------------------------------Liquid depth------------------------._Capacity----------------------- isposal Field: Distance from nearest well.��0-_____Distance from foundation----3.0._.r._Distance to nearest lot line-----2Q.... Number of lines___.____ILength of each line______ _ __ ____ ! Width of trench___ __((_`.____.__________ _ ------------ �5`' f Type of filter material__ _�1______________Depth of filter material____.. ,f.._.._.___Total length_______} Seepage Pit: Distance to nearest well- _______________Distance from foundation--------------------Distance to nearest lot line----------------- izq ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--..-.-.----_--------Depth.......------------- Cesspool: --------- _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-----------------------------------------. .P 3 ❑ Distance to nearest lot line_____________________________ Remodeling and/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, FAtAte lays, and rules anj regulations of the San Joaquin Local Health District. (Signed) ---- --------- [Owneremdfer Contractor) ----------- --------- ----------- - ----- ---------:------- BY: - ------ •-••-- � r {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-- - -- REVIEWEDBY----------------------- ..... -------------------------------------------------------------------------- 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 14544 PT WPI]o 12-54