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R� APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) .Oats Issued,- llt' Application is hereby made to"fhe San Joaquin Local Health District for a permif to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549., j I{ �l .�J JOB ADDRESS AND LOC TION b` 1lL1LQ ��' ` = G+'—r---••- -----•----------------r----- Owner's Name----- --- ---------- - ---- 0� -- ------- ............. Phone--------- •---•- -- 7- ... .. . Address_______ __ ._ -- Contractor's Name....-- --- —:_ ----------- 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 ❑ Community system ❑ 'Private J2�_Depth to Water Table 6--d 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 k No ❑ 4 r TYPE OF INSTALLATION AND SPECIFICATIONS: l .� (No septic tank or cesspool permitted if public sewer is available within.200 feet.) �� ...0,Septic Tank: Distance from nearest well--.�_____...__Distance from foundattiiorn_:._____.. ________ ____________. No. of compartments..-,_---:Z--,---,---- ------ .____.__Capacity___ Disposal Field: Distance from nearest well..... d----Distance from foundation_z,c� ._ _.Distance to nearest lot lin Number of.lines_______.__ /�Length of each line______-__ 1 �, Jidth of trench_._._ - __a - T e oT filter materia__%i; �.Krl]e th of filter material...... ._.g: ! Total length --________________ YP -�---=r P � -� g / See�ppa]ge Pit: Distance to nearest well__ __.___C�.______Distance fr, f undation_.../l3.:...___.Distance to nearest V C ---- P — g ��Depth .�� Number of pits-------- ------Linin material__ Diameter__...___ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-_._____--_-_------ ---------------LC-1 ❑ -Size: Diameter---- :----- --- ---------- --- Depth------- -------------------------- ".____Liquid Capacity----------------------------gals. Privy: Distance from nearest well____________________________________________ ___Distance from !nearest building------------------------------------------- El _______________------__:__ ._._._ .❑ Distance to nearest lot line---- -- ---------------------------------------•---------------------•-------- ---------------------------------- Remodeling and/or repairing (describe): ------ _..---.:_..-•---......---•------------•-•--•- ------------ - --------------------------=----------------------------•-----•----------------....---•--------------------------------------------------•----••-•-------------------- w ----------------------------- ----- ------- -- --------------- -----•---------- •--------------------------------------•---------------------------------------------------------------------- hereby certify that 1 have prepared this application and.that the work will be done in accordance with San Joaquin County ordinances, State s nd rules and regulations of the San Joaquin Local Health'Dis+ric+. (Signed)- ,.�-I--- -- -- ------- --=---- ----------------------------------------------(Owner and/or Contractor) = --- Ti+le (Plot plan, showing size of lot, location of sys+em in relation-fo wells, buildings, etc.; can be placed on reverse side). FOR DEPARTMENT USE ONLY, APPLICATION ACCEPTED BY------------------- ------ DATE-------- ------------------•-- ---- ----------------- REVIEWED BY ----- ---------------------:----------------------------- - DATE----------�- BUILDING PERMIT ISSUED----------- •--•--------------- - - ------ DATE-- t� Alterations and/or recommendations:__........:.......:.. .. . ...................... ' � __---:______._:f---------- ---------------------- ___ __ ._. .. ------ --- ----------- ---- ---- ----------------------------------- -_..-. ---------------------------- FINAL INSPECTION BY:......- _' - -=........................ Date"-,� /1., 4J ,: SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9 i<saac aTwaoo