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APPLICATION FOR SANITATION PERMIT Permit No. r 4. (Complete in Duplicate) I} Data Issued Application 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 AND LOCATION----- .,E.._.__.... Owner's Name-------------------------&WY§lE_ Phone- Address---------------------------------------------•----- -JV L ...... Contractor's Name------------------------••---------------------------------------------------------------------------------------------------------------•--- Phone----------------------------------- Installation will serve: Residence 99 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ / � y Number of living units: ___ ___ Number of bedrooms __/___ Number of baths _ ___ Lot size ----------------------- 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 ❑ Adobe X Hardpan ❑ Previous Application Made: Yes ❑ No N New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material--------------- --------------------------------- El .- _----__.___---_______-.__.-.❑ No. of compartments-------------------- - --Size---------------------------- ---Liquid depth--------------------------Capacity----------------------- Q� Disposal Field: Distance from nearest well-----------------Distance from foundation-------------------.Distance to nearest lot line..__________--_ \ ❑ Number of lines----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material____.___._._.______._Total length---------------------------------------... (` Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- F ----- ________ uuu111 ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth-----------.--- ------------_--- L 4 ; Cesspool: Distance from nearesfywell _ _Distance from foundation.____`�_____..Lining material-----.��-__ �' Size: R;&W&-ker----- �l ----- -- ----- Dept h------lv---------•-------------------------------Liquid Capacity ---- ------.gals. Privy: Distance from nearest well---------_---------------------------------------Distance from nearest building___--.-._--______.___________.____..._ ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe): -------------------------------------------------------------- ------------------------------------------------------ --•--------•-•------------- .-------•----------------------- - : = - ----------------------------- ___ ___ ____::_:__::__ :__:_:____-:__ _ ____.-. -______________________________________ ___________ _____________ _.__..______________________ __________.__..____.________________________._.____-__________..___._____._ ..- -_______---__-._...____. I hereby certify that I have prepare thi application and th t the work will be done in accordance with San Joaquin County ordinances, State4aws, and rules and re ulations pf the San Joaquin Local Health District. r (Signe - - ----••--- --------------------------------------------------------------{Owner and/or Contractor) By:------------------••----------------------------------------------------------------------------------------------------------------(Title)-----------------------•---•------------------------------- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be Placed on reverse side). FOR DE TMEN,T USE LY 011011/APPLICATION ACCEPTED BY----- ATE------- REVIEWED BY DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------- Alterations and/or re omme dations:- ----- i ` --------_.______........___._..._-._ ---- - •- -----.-----•-••-- ••-•------------------ --- --------------------•--------------•-•-------------- -- -----•----•----- - ----------------------------------------------------------- ------------------- --------- --------------------------------------I- ----- --- ---- --------------------------------------------------------•----------------------------------------------------------------- FINAL INSPECTION BY:------e 2�__-^! _ � Y ----------. Date-- SAN ate-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 E5-9-2M 10-52 Revised W-2100