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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) � -- - Date Issued ___,�?l_Y Applica}ion is hereby made to'the SanJoaquinLocal Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance o. .549. " E JOB ADDRESS AND # LOCATION__-------9Z ---------- ------------- -------------------- ---------- _Owners Name___.____ �. rP h / - Address---------•• ------- ---•-----------------------------••----•------•---------- Contractor's Name-_.--�_____ ----------- IZ --------------------- --------------------------------------------- ------------ ----------••------ Phone----------------•------ . - ----------- Installation will serve: Residence ❑ . Apartment House ❑ Commercial ❑ Trailer Court ❑ .Motel ❑ Other ❑ Number of living units: ------- Number of:bedrooms -------- Number of baths -------- Lot-size ___________ _____________ _ ---------------------Water Supply: Public-.system'❑ C' h-imunity system ❑ Private ❑ . Depth to Water Table'------- ft. Character of soil to a depth of 3 feet': }Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ , Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑' New Construction: Yes ❑ No ❑ TYPE.OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) _-_____.Distance from foundation---------------------Materia: _ _ _ _ ~r Septic Tank: Distance from nearest well:.:--' � � No. of compartments-- -----------------------Size----------------__- -----------Liquid depth------------ -.. .-.--.---Capacit ----------------------- Disposal ❑ Number of lines---------- ------------------Length of each I;ne--------------- -------- Distance to nearest lot line------ Field: Distance from nearest well-----------------Distance from foundation _ .•----..Width of trench - Type of filter material:i--"__-----------------?Depth of filter,material----------------------- length--------.------------- N ❑g o Number of its________________�_-_Linin Distance from foundation___W--___+__-__:Disfiance6to nearest lot line-____---___-_--__ p g'material-------------- :-----Size: Diameter------------------ ----.De th---------------------------------- -,Cesspool, See a e Pit: Ditance to nearest well_____.__.--_:. p 1 i f i Distance from near t welly_ --------Distance fr foundation r .....Lining material____ W Size: Diameter---- .� De th .,o, 4 . ,... p p - .. ... - ;a Liquid Capacity------------- Privy- .- --- U• .gals. Privy: Distance from nearest well_____ _________________._-----------------------------__F_-Distance from 'nearest buildin .._ ,�:. Distance to nearest"lot'line. -�: � ------------1, .,�... .� � -� - - --------------- Remotleling and/or repairing (descrikeJ_____ __ _.�__ - - �,tJ �� _______________ _ ____ _______.._ - _ _•___-__-».....'....__•- ._..___ i -___.___ .-___-__ -------- -- _.___Ys�__ ____. _________________________________________________•--______ _-_- ___..-__ ..______.._ } ____________________________ _________________ ____________________________________________________________________________________________________ __________________________________ 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 rules and regulations of the San Joaquin Local Health District. (Signed Y- --------- ---------------------------------------------------(Owner and/or Contractor) ! Y --- :-------------- (Title) -- ---------- (Plot plan, showing size of lot, location of.system in'relation to wells,-bruildings, etc., can be placed o'on a ease `side). ` T " ` F FOR DEPARTMENT USE ONLY APPLICATION `----------------•-------- DATE----- -- -- --- REVIEWED _______ __'-_A____--______.-_________.__._ __ RI VIEWED BY BY ----------------------=-- ------ DATE------ -- - ------------------------ ------------------ - --------------- BUILDING PERMIT ISSUED _ ------ DATE ----------------------- Alterations and/or recommendations:____________________ ----------•--------------- i ------------------- ---------- -------------------------------�--------- = ------------ ------------------------------------------------------------- ------------- ' ----------=------------•-------------------------------------------•--•-------- -- -, FINAL--INSPECTION BY:-`:--. =-----------------------------------------------�. _ - - --- Date----------- =� = __ = ... _ P 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 '7 5-4-2M Revised W-2100