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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. y� JOB ADDRESS AND LOCATION_______ _ _________ ______ ----- "�"� = ,vyrf=l ��'�' --- _./.its.------- ---------------------------- Owner's Name /s_-lv'� _�tr�-- --------- -------------------- ------------ Phone.11 - . Address----------- .' ------ d ------------�� ------------------------•--------------------------------------------------------------••------...-•---•--------- Contractor's Name__. --------------------------------•-------------------------------------------------------------------- ------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1----- Number of bedrooms _r)__ Number of baths ----I--- Lot size D---------------------------- Water Supply: Public system ❑ Community system ❑ Pfivate ® Depth to Water Table 6O-_ ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: Yes ❑ No [4 New Construction: Yes 5� No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Y (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__IP-------Dista ge from foundation__.4_d_=__.____-MateriaL_elp-----___._---__ _________- `T No. of compartments---------X--------------Size------.. •---�' .--- ------Liquid depth------.Y-----------------Capacity.90-0------------ Disposal Field: Distance from nearest well___§ fl_.....-.Distance from foundation----ff__9----....Distance to nearest lot line.__-Z_-_______- ,Number of lines-----------D,- ------- ------Length of each line----_6.0.------------------Width of trench___'A__4f----------------------- Type of filter material-- f�'rimxk----Depth of filter material-__.I%"-----------Total length-_- ______________ ,Seep—age_Pit: Distance to nearest welk----------------------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------------------------- ------------Dept h-----------------------------:.---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------- ------------------------ ------------Distance from nearest building------------_---_____________..__.____._. ❑ Distance to nearest lot line----------- -------------------------------------------------- ---------•-------•-------------- ------------ -- ------------ Remodelingand/or repairing (describe):----- - --------------------•---------------------•---•------------ ------------------------------------- -•----•------•----------------------------•--•- =-----------------•------------------------------=------------_-------••-------------------------------------..-...------_---------------- 4 y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)__.-L-I�-)�-- � Owner and/or Contractor] -------------------------- --- ----------------------------------------•------------------------------( ) h' --------------------------------------(Title)------------------------- -- .(Plot .plan..showing size of lot, location.of system in relation to wells, buildings,--etc., can-be-•placed-on--reverse--side). —°'FOR DEPARTMENT U-SE ONLY A p APPLICATION ACCEPTED BY -�' rr_ 1 ------------------------------------------------------- DATE-//--J 'J-�------------------------------------- REVIEWED BY------------------------------------------------------- --- --------------------------------------------------- ------- -- ---------------•---•--- ---------------- DATE----- ----------------------------------------------------- BUILDING PERMIT ISSUED------- ----------------------------------------- •------------- DATE------------_ -- --------- •----- ------------------------------- Alterations and/or recommendations:---- --- ----- ---- -------- - ------ -------------_-------- - ------------------------•---•--•---•---- .-•---- ------ ----------- .... -------------- -------------- ----------------------------------------------------- ---- -•�-- �a ---•-•-----------------------------•- ------ •-- • --------------_/------------------ ---------------------------------------------------- -------------•---------------- -- - ----------------------------- ------------------•------------..------- ----------------.-----------------...-•--...------- FINALINSPECTION 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 E5-9 145446 ATWnnD 'k L