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APPLICATION FOR SANITATION PERMIT Permit No. ................... .1__. (Com lete in Duplicate) P Date Issued ..._ . Applica+ion 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 a -------- ------- 1, ............t"--.---- Q1 �,0 ------ Owner's Name / . .� .- „ Address--------- Contractor's Name-----P..�)/ � ' Q`�s? u,._�._.. -...... Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 • Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ......._ Number of bedrooms -------- Number of baths __/--_ Lot size ----: -_.�.:7_....................... Water Supply: Public system R 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 P3.,Hardpan ❑ Previous Application Made: Yes ❑ No C& New Construction: Yes I& 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 [� well._- �O'&4iistance from foundation_--_7Q__......Material,_L_e--- ......... No. No. of compartments_.__.-.„�----------- .....Liquid de th_....(G.? -----------Ca acity., ;! Disposal Field: Distance from nearest well---/_0 " ..Distance from foundation-----fid---------Distance to nearest lot line......,'J`_...... VL Number of lines-----------/.--r-----t-----. - Length of each line-------------- �_�_.Width of trench--------��.1- ---------- Type of filter matenalJ.�.__.1.g Depth of filter material--------- -Total length--------o;......................... Seepage Pit: Distance to nearest well-- Distance from foun4at•on..... � ..Distance to nearest lot ne -`' .0 € Number of pits_________J `____________Lining material.-(1_tti-_r_�✓_f-�&kl�: Diameter._:.: _.+_.__.___ Depth Cesspool: Distance from nearest well-----------------Distance from foundation.- _---.--_----.Lining material-------------------------------------. ❑ Size: Diameter--------------------------------------Depth-.-----------------•------------------------- ------Liquid Capacity............................gals. Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building------------------------------------------- Distance --.-_ ._--____ -.:.-------.-_.-.Distance to nearest lot line-------- --------------------------------------•---•----------------------------------•--------------------------------------- ----- Remodeling and/or rep •r• escribe):--------------------------------------------------------------------••-----•--•--------------................................1------- .......... ---------•-- ----•----•--•-•----•-•----------------•----------•--------------------------------- ---•----------------•--------- ----•-----------------•-•-••---•---------------------•-•--•----------------------...•--------••----------------------•--------------......------.................. ... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County -_ ordinances, Ste s, and rules and regulations of the San Joaquin Local Health District. (Signed)------ = ------------------- --------------------------------------------------- and/or Contractor) ----------------- Title (Plot plan, showing size of tot, location of system in relation to wells, buildings, etc., can be placed on reverse'side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------- ---------------------------------------------------------------------- DATE----------................................................. REVIEWED BY------------------------------- ------------ ------ DATE------ BUILDING PERMIT ISSUED................. DATE.......................................................... - -------------------------- Alterationsand/or recommendations-----------------------------------------------------------------------------------•---------•---------------•-----------------•-•................................... ---------------------------------------------------------------------------------•...----••---.....................................•-----------------••--•--•--•-•....-•---•---•-•••--•----------•--•----•--•.....------•-- _. ----------------------------------------- ------------------------------------------------------------............................................................. ---------•-•--•------•--------------------------- ------ -------------------------------------•-------------•-----------•-••--•-------•------------------------•----•----•--..._.....••---------•-•--••--••--•---•--------•----•-•---•---•---•--........•-•---------•-----•---------•- FINAL INSPECTION BY:._ --------•--• Date. ---`- ' ._ _ 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 ATW000 12-54 _