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APPLICATION FOR SANITATION PERMIT Permit No (Complete in Duplicate) jV r. Date Issued /ThiApplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein`described. s application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATION-------------f _ Owner s..Name-- -C N �_)_ -?� . .: ?W_� " - ------ Phone__...- - Qs�. Address---------------- -• ---- _ - r--- Contractor's Name________________________ Phone_` _ - - -------•-- -------------------- ------------ Installation will serve: Residence House E]Apartment HouCommercial E] Trailer Court ❑ Motel ❑ Other ElNumber of living units: _1___ Number of bedrooms-- Number of baths ` -•--- Lot size ------- afar Supply: Public system Community system ❑ Private ❑ Oepth to Water TableZ.-"ff. Character of:soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay E] Adobe, Hardpan [] Previous Application Made: Yes ❑ No New Construction: Ye No ❑ Il TYPE OF INSTALLATION AND SPECIFICATIONS: I+ (No septic tank oi,cesspool permitted if public sewer is available.within 200 feet.) 6 Septic Tank: Disfance from nearest well Distance tom foundation_-/p--------Mat@ria___ No. of compartments__--_ -- � ,�� `� �� Size_. Liquid depth__. ------- ...... - Capacity-----�� [ Disposal Field: Aj Distance from nearest well_______________ Distance from foundation___-________-___-_-Distance to nearest-loft line__-________-___-_ e• R ❑ Number of lines-----------_.......-___-___ Length of each line__________-:_____ ------Width of trench- -------------------------------->j Type or filter material------------------------Depth of filter material--------------_-r-----Total length------------------------- 1 , j Seepag Pit: Distance to nearest we[t. / ----_Distance from foundation__._ �A�__________ Distance to nearest lot line_:-�-__-_• Number of pits. l -------------Lining materral .Size: Diameter__--- ��---------Depth------��- ------------- � Cesspool: Distance from nearest well________________Distance from foundation------_. ___-__ Lining material-----------------------p_- ❑ Size: Diameter_: - - - Depth------------------- --------Liquid Capacity- Privy:' nvy: Distance from nearest ------ --------- ---------------Distance from nearest building -1 ----- - ----_ _.» . g --------- -------------------------------------------------- -- El Distance to nearest lof'linew"-_: __ ---- ------------------------ --- Remodeling and/or repairing (describe)_______________ ___ ___� a l ----•--------------------------------------•-----•-------- ' -------•---•----- ----•----------------••--•--------•-----•--•---------•----------••----------•-----•-----------------------•----------------------------------------•-•---------- --------------------------- -------------I--------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i` ordinances, State l ws, an ules•and regulations of the San Joaquin Local Health District. (Signed ------• = •-- --- -----------(Owner an or Contracor) - (Plot plan, showing ze of lot, location of sysfem in relation to wells buildin s, etc., can be r - e 9 � on reverse rdeJ. FOR DEPARTMENT USE ONLY 1l APPLICATION ACCEPTED $Y_ DATE; REVIEWEDBY ----- --------------------------------------------------- -- ` --------------------------------------------•---------- DATE_ r BUILDING PERMIT ISSUED----------------- •----------___--- ----------------------------------•--------------------- -------- DATE------- -`------------------------------------------------- s:Alterations and/or recommendation ___________________________ ' ----------------------------•-- ---------------•-•---•---•--------•--•----- .._._.. 4 ------------------- ------------------------------- •-------------- •--------•------- ------------------- -----•------- ------------------------ FINAL INSPECTION BY:...... Date__ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore S}ree} 814 North "C" Street Stockton, California Lodi, California w Man}eca,'Callfornla Tracy, California ES-9-2M 10-52 Revised W-2100 ''