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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) [}ate 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 compliance with County Ordinance No. 549. JOB ADDRESS AND. LOCATION .. 'j [� o------------------------------ - --- ----------------- 4 4� --- ------- "t,e..49 Owner's -------------------- -- - Owner's Name__________ ___ _.- _ •WAparfmf .GtJ---- Phone--------- ----------------------- Address----------------�------ f / --------- .- �!L/ Contractor's Name---------------_-----•------... ---------- •---------------- E� ------ Phone----------------------------------- Installation will serve: Residence) se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I-___ Number of bedrooms Number of baths ----'-- Lot size .-..- -- Y� ..__________----- Water Supply: Public system ❑ Community system ❑ Private Ix Depth to Water Table /tv--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes A No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well______Q___Distance fro foundation___J_a____._-Materi I__________ _ _________________ p No. of compartments__- P-_--.----Size___ - ____Lic}uid depth___-.- ___.____ Capacity_____ Q� �irn r - Disposal ` Field: Distance from nearest well__ U_._'Uistance from foundation__-7__?_:0Distance to nearest lot line.-I-0____ Number o.1 lines_____________�.____ length of each line_________,1,I z -.-.Width of trench------ ----_------ � � Type of filter material-_s`��_1_Depth of filter material--------f Total length_____ ------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation____..-.________-__.Distance to nearest lot line_.___-_- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------------------_---_ Cesspool: Distance from nearest well-----------------Distance from foundation..------------------Lining material------------------------------------- El _._________________ _____❑ Size: Diameter__ ------------------------- ------Depth--------------------------------------------- --:m-Liquid Capacity-------- -------------gals.: Privy: Distance from nearest well-------------------_-----------------------------Distance from nearest building ❑ Distance to nearest lot line-- -------------------------------------------- -_-------------------------------__---------------------------------- ------------------- Remodelingand/or repairing (describe):-------------------------------------- ---------------------------------------------------------------------------------•-------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- ------------- I hereby certify that I ha prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta law and r es and egula 'ons of the San Joaquin Local Health District. ' --- -- ------ --- --------- ---------- (Signed) (Owner and/or Contractor) By:-- ------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------------------------ (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------------- -- -------- ---------------------------------------- DATE-------------------------------------------------------- - - REVIEWED BY------------------------------------ DATEr' '" _ _ BUILDING PERMIT ISSUED________-__ ----------------------- - ----- - -------------•�--_- -- ------ ---------- =-------------------.�.: _ Alterations and/os recomm a#Fo1+s:. ------------------ } ------- :::::::-:----------------------------------------- ---------------------, ' :: o::�Ap=------------------: :- -- ---------------------------:-:------:--:--------------:---_--------------- FINAL INSPECTION BY:------i-------------- ------- ---------- Date-----------�a_-_.16----- SAN JOAQUIN LOCAL HEALTH DISTRICT UD 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 10-52 Revised W-2100