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V ('4 T _ APPLICATION FOR SANITATION PERMIT Permit No, _ _'Z_----f (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 A D LOCAT ON.._L. .. ....-- -------- -------- ------ -----------------------------------------------•- -•---- Owner's Name.-..--• ---- -- -•----•--- / ----------------------------------------------- ------------- Phone--------------------------------- Address...... - ---• ---1------{ Contractor's Name___ __ . -- Phone�_�?-�_-.2• ( ( _ Installation will serve: Residence Ef—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ Number of bedrooms _;3------.- Number of baths __� Lot size ---- Wafer __Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table /_-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adober Hardpan ❑ Previous Application Made: Yes 0 No 9 _New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: Septic Tank: Distance or cesspool permitted if public sewer is available within 200 feet.) No septic-tart r f p from nearest welt-___.._-_______Distance from foundation---->�tv....----Material -. __Size__ -- t`� w No. of compartments..__.-..-Z..____._. ___4d_.___Liquid depth.... .. .............Capacity_..__ _�_____..___ Disposal Field: Distance from nearest well-------------- --Distance from foundation-__14P.(....Distance to nearest lot line_--1� ------- Number o; lines__________ ______ ___rrr___ Length of each line---- ----------Width of trench.__,-Sj ---____.___..._____-_ Type of filter mate rial___.r.- ....._/ / Depth of filter material-------/ ----- __..Total length---. ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot lint--__..___----_ ❑ Number of pits---------------------Lining'material-----------------------Size: Diameter------------.---- -----Depth--------------------------------- �. Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material---------___---- ----.__:----__.-__--. (� ❑ Size: Diameter------------------ ------Depth-------------- ------------------------------------Liquid Capacity--------------------------- Privy: -------•--------•-------Privy: Distance from nearest well--------------` ----------------- ----.-Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot fir�e------------------------------------------------------------------------ --------------------- ----------------- a Remodelingand/or repairing (describe):-------`-----------------k-----------------------------------------------------------------------•-------•---•-------------------•-----------•----•--•---- . ---------•----•---------------------•--- -------------------------------------------- -------------•------•---------------•---- • 'u ----------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State, laws, and wle and regulations of the ,San Joaquin Local Health District. (Signed)----- -- ------ --- -- ---------- ----a� --- ------------ {OOvne. r Contractor} BY= - - -------------------. (T )-------- s --- itle (Plot plan, showing size of lot, location of syitem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- - - ----- - ---- -------- --- -----------------------•--•--•---------- DATE------�! REVIEWED BY-------------------------- ----- -- - DATE------------ //-------- ---- ------------- ------------------------------------- � t--- BUILDINGPERMIT ISSUED--------------------------- -------------------------------------------------------- ------------- DATE,e ? - Al efatiohs and/or recommendations:: - f ^ •-------- A.Q.A. --------- -------- _ i q t r .. --- --- FINAL INSPECTION BY_.........______________________5------ -- J � 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-` 2m 1454x6 ATWODD 1y- 4