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APPLICATION FOR SANITATION PERMIT Permit No,_,:�(,"4.--J�.��-- (Complete in Duplicate) Date Issued ��/---y' 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. 544. 1 -- --------- ------------------------------------------ JOB ADDRESS AND LOCATION.______. 2 Owner's Name-------------- -k------- _th-t o- ------------------- ---------- - I ------------------------------- Phone---------------------- Address-------•------------•- ---- � ----------------------'11_4--- °L=-------------- Contractor's Name------------------------------ d.-- -------------- - , ---- - Phone--------•------------------------ Installation will serve: Residence.0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/--- Number of bedrooms .--/-- Number of baths'--/--- Lot size __________ ______ Water Supply: Public system g Community system ❑ Private ❑ Depth to Water Table -------- ft. n Character of soil to a depth of 3 feet: Sand ❑ Gravel F1Sandy Loam ElClay Loam El Clay El Adobe El Hardpan E] Previous Application Made: Yes ❑ No 0- 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_______--__._.__.__-__________-_----------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------.Capacity----------------------- 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 finer Material-------------------------Depth of filter material-----------------------Total length-------------------- ' Seepage Pit: Distance to nearest well_______________ ______Distance from foundation----------.---------Distance to nearest lot line____-______-_____ ❑ Number of pits------------------ --- g Linin material---------------------- Size: Diameter----------------------.Depth--------------------------------- Cesspool: Distance from nearest well ____------------Distance from foundation--------------------Lining materia___._______"""----------•--""--"els. ------Liquid Capacity---------------------------•g Size: Diameter--------------------------------------Depth _. ' Privy: . Distance from nearest.well__----------------------------------------------Distance from nearest building-------------------2-------------=---- ❑ Distance to nearest lot line--------------- ------------------------ -----------------------•------------------------------------------------------ ------------------ t R modeling and/or repairing �c[escribe): "--- ,---------- -1-- -------- -- `� �)- - ---- - ------- --- 4 _S____ ______ _____ _________ ________ -------- --- _ __ _________________________ ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I , and r s and re ul tions of the San Joaquin Local Health District. C .......... ------. ----------------__.___-_____(Owner and/or Contractor) (Signed) ----------- - 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-------------- -- - -i--5-�"- ----------- REVIEWED BY-------------------------------------------- ------- ----------------- ------ DATE----------------- -�------------------------------ BUILDINGPERMIT ISSUED----------------------•------------------------------------------------------------ DATE------------------------- --------� -- � ---- ----------- ---- - Alterat o� ns and/or recommendations:------------------------------------------------------ / ---------- ------5 ..4.�- ----- "r�- -- - ---- ---------------- --------------------- ----------------------------------------------------------------------------------------------------------- ---------------- ---------------- FINAL INSPECTION BY------------------ ---------- Date------l- �_/- -- ' y SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y. E5-9-2M 8-51 Revised W-2100