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APPLICATION FOR SANITATION PERMIT Permit No. ..... ................. (Complete in Duplicate) 3 Date Issued ...... ._? Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereindescribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCAT ON_ J' ___-.__ �0.__._1G!k!7!'Jh ----------- Owner's Name v�.• ------ Phone -------- ---------------- Address m-T`� -�'�--� '� -••-- - ------- Contractor's Namee �!!��a..�. Ph n `4 • Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ er ❑ Number of living units: _14----- Number of bedrooms _ Number of baths J_.__ Lot size407V----__�_��^�........................ Water Supply: Public system WL.Community system ❑ Private ❑ Depth to Wafter Table �.M. ft. Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobef ""Rardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes A__"o 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 •- _---_Q._. ..Material No. of compartments_____- Size-41 j Ca Capacity---- ...... Disposal Field: Distance from n est ------Distance fromAoundation.....f_O _-Distance to nearest lot line__ AR ___ Number of lines.-_._ ._. _ Length of each line..... 11�_ Width of trench Type of filter mat __ _-_ft—Depth of filter m I_ __I_--_ _Total length__.__ `__: ..______.. Seepage Pit: Distance to nearest well ______ ________Distance f fou da ' . !�...... 'stance to neares g£jine-J_0...... Number of pits_-_____/-__________ Lining material__.. } Siz Diameter____ �_ .._.Dep ___.I-`__________ Cesspool: Distance from nearest,well.................Distance fro foundati n -___--___-______"Lining material__ `_ " ❑ Size: Diameter--- --__: -_----Depth----------------- -•-- ---------------------------Liquid Capacity---------------_ ---------gals. Privy: est well ___ - ____-_____ Distance from nearest building ____________________________________ Priv❑ Distance to nearest lot line-------------------------------------------------- Remodeling and/or repairing (describe)-------------------------------------- ..---------..,-- --------•----....... ---- •-------------------• ------•. -----• -----•-•--•--•------------•----------------------------------------•------------•-------•-•..------------•--------------------------------------------------•--------=-------------------•---------------------..------------ ------------------------------------------------------------•------•-----------------•------------------------------------•--------•-------_------------------•---------------------------------------•--------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----- � -•--- - -''~"� ! *""Q----------- ------ By: ---- r Contractor) By:••-••--•+ ___... I._...._ -�•- ---- ...............(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 BYDATE-• -- REVIEWEDBY--------------------------------------------------------- - ------ DATE.......................................................... BUILDINGPERMIT ISSUED-----------------------------------.................................. /................ DATE------------------------------------------------------------ --7_1---- Alterations and/or recommendations:------------------------------------- -- --............................................................................................. -------------------------------•----- ---------••--------_.. __... -- --------------------------------------------------------------------•---------------------•-----------=--------------------------------•-- 4 ----------------------------------------------- ----------------------------------------------------------------------------•-----------------------•----...-----------..-----------....------------------------------------- -----+--•--_---------•-------------------• •-•------------•-----•_..--•---------.__.__._._._._..•--------•-_•--•-------'--- _. -----•----------___--------___----_____--- FINAL INSPECTION BY: 11�',t. 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 ES-9-2M Revised W-2100