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APPLICATION FOR SANITATION PERMIT Permit No_ ____ {Complefe in Duplicate) Date Issued Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct d insta he work herein described. This a plication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIO Owner's Name___- 40 r _---------------- ---------------------------- Phone... Address. -------- Contractor's Name_____ ________ Phone - y.�� ♦ _ Installation will serve: Residence . House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: f.___- Number of bedrooms-.- Number of bathAiLLot size ___-- Water Supply: Public system '❑ Community system ❑'4 Private && h to Water Table,?ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ar pan ❑ Previous Application Made: Yes ❑ No [5'- sw Construction: Yes 6_14 --tt- TYPE OF INSTALLATION .AND SPECIFICATIONS: (No septic tank or cesspool permitted if sewer is available within 200 fee}.) Septic Tank: Distance from nearest we r �a p ��__..__Distance from foundation___ ._ Material .... t No. of compartments_-.._ ._______-_---Sizer-( Z- _-10 Liquid depth... Disposal Field: Distance from nearest we a °- Distance from foundation___. -�.._ Dis#ante to nearest lot line-- .... Number of lines_____ ________ .--- Length of each line___ - g - - Width of trench.._-�--V' � O -- - Type of filter material-__. __-__ -_ ___---Depth of filter materiah_._. .-.- --.Total fen th___-_ W .� g Seepage Pit: Distance to nearest well__-.x'25----:_Distance fr m fo dation___-- r ___..Distance to nearest lot line.-_r_1t-______ Number of pits------ ______________Linin material-- S' � i° --De th-__.a Lining - - _ - ¢e: Diameter_._-- -�--�- p If Cesspool: Distance from nearest well_________________Distance from foundation_-----__ -. ------.Lining material-- -------- ----------•-----=-----• .❑ Size: Diameter--------------------------- ----------Depth------------------------------------- --------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well ❑ Distance to nearest lot lire---------- ___ __________ __--_____----------------Distance from nearest buildin ilding------------------------------------------ _____....____--.._ ------------------------------ Remodeling and/or repairing [describe):--- _- c-_ - -- '----------•--------------•------------ ----- -- • -- Q ` - G ------------------------------ ) ---------------------------------------- -----------------•------------------------------------- ---------------------------------------------------------•-----------•---------------------------- -------- I hereby certify that I have prepared this application and4hat the work will be done in accordance with San Joaquin County ordinances,:- to I s, a rules an regulations of the San Joaquin Local Health District. (Signed)--- ----- -- - --- -- --•-- -• ----- --------------Z_ __ - -------- --- ------ ----- ----------------------•-----------------•------------ By- . ..--- ontractor) . ------•------------------------•---•--------(Title)--•-----•------------------------ ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------'-------.---__- - -- -- DATE r REVIEWED BY_ ------------------- ------------ ------ --- - -- ---- ------------ ----' _ DATE-------- ----- BUILDING PERMIT ISSUED-------------------►-__-- --- ---------------- -------- -- - DATE ----------------------- aerations and/or recommendstions ____--- ---------------------------------- Alterations and/or u ----- . _/ - ------- ----� j. f. ---- -; -----• ---------- -- _ -------------- ----------------- --------------------------------------- - •- ------------- - ----------- - ---- ----------- ----_ --- ••--------- ----------- -------- � � µ FINAL INSPECTION_.BY:_. ------ ---.----- ----`+------ Date---�--'.._�� ,r SAN JOAQUIN LOCAL HEALTH DISTRICT 11 130 South American Street 300 West Oak Street 132 Sycamore Street 1814 North "C" Street Stock+on, California Lodi, California Manteca, California f Tracy, California ES----9-2M 14544B ATWOCO 1254 ��