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APPLICATION FOR SANITATION PERMIT Permit No. ---- - . (Complete in Duplicate) 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 No. 549. JOB ADDRESS AND LOCATION..-h--r' ------ -1.07-4---------------� Lro �`- ------------------• ------- --------------- ------- Owner's Name--- ------- ----- Phone------------------------------------ Address- - ----- - Contractor's Name.--- ..... ----------------------------------------------------------------------------------------------- Phone/�".�' Installation will serve: Residence ❑ Apartment House 4 e_ mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -4---- Number of bedrooms _4(---_ Number of baths -..-- Lot size - - -l6--.O&A.AA � Water Supply: Public system ❑ Community system ❑ Private @4-Depth to Water Table -12- ft'. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam &j Clay ❑ Adobe❑ Hardpan ❑ 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.) Septic Distance from nearest well ------Distance from foundation------------------ Material----------__-_-_--------.----------------------_. No. of compartments------- --- - -----------Size-------------------•------------Liquid depth--------------------------Capacity...-------------------- Disposal Field: Distance from nearest well-,/_0_.__'__ __Distance from foundation---.,3-0-_'-.--.Distance to nearest lot line---�_---_-_-. 61 Number of lines----._-a ----- ;--------------Length of eachdine/X --�--�`-.��---Width of trench----Z=-y-!'------------------- Type of filter material---1- ,--.-_-----.-_-_Depth of filter material -------Total length_-_--3a -------------------------- 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--_-.-------------------- ❑ Size: Diameter--------------- -----------Depth----------------------------------------------------Liquid Capacity_. Privy: Distance from nearest well ---------------------------- ------Distance from nearest building-----.--_.---..--_------_-.-- I ❑ Distance to nearest lot line-------------------------------------- --------------------------------------------------------------------------------------- Remodeling and/or repairing {describe):--------- --------------------------------------------•-•--------------------------------------------------------------------------- -- -----------------------•-------••------------------....-------•----------------•-•-••----------------------•- ------------------,---------------- --------•--------------------------------. -------------------•-•---------------------•--•------------------••----.-------•----------------•-----•---••-----------------•---•---------------•-•------------•-----•-------------------------------•---•------------------ ------------------------------------------------------------------ ----- �- I hereby certify that 1 have prepared this application and +hat 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) Rot -------------------•----------•--..... ((a�rherawContractor) . sY� [Title)------------------------- -------------------------------------- (Plot plan. showing size of lot, location of system in relation fo wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- ------- DATES -•- /� REVIEWED BY - ------------------------------------------ ---------- DATE BUILDING PERMIT ISSUED----------------------------------- ------ -- ------------.--------------------.......- -/--------- DATE• ----------------------- --- --------------------------- Alterations and/or recommendations:------------------------------------------------------------------------ -------•-•------------------•-----------------------•---------------------- ----------- -------------------------------------------- ----------------------•-------------•----------- ` - ------------ ----------• ------ ---- ,-..-.._.. - ----------------------------------------------•------------------------------ ------ --------- T -----------------•-----•-- ---------------------••-•-------------------------------------------- -------------------------------------- ---- - ------------ ----'----- -- -------------------------------- ------ ..--- --- - - --- I --- � m� FINAL INSPECTION BY:... Date------ '.-. r ---- 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 E5-9-2M 145446 ATWQDD '12-54 1