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APPLICATION FOR SANITATION PERMIT Permit No. /v o b ...... l�l l (Complete in Duplicate) Date,.lssued 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__ Au - ! �✓ f /i��Uo <_42.�-'�------------------------ Owner's Name-------------- ------ Phone------------------------------------ Address------------------- -------^v------------- ----------------- -------- ----------------------- -------- --- ---------------------- Contractor s Name li �r f----•--------------------------•-------------- Phone �. Installation will serve: Residence ❑ Apartment House E] Commercial [-] Trailer Court E] Motel E] OtherA Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ----- Z X_..3.�Ca__________________ Water Supply: Public system ❑ Community system ❑ PrivateK Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam;& Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes p No jq, New Construction: Yes No ❑ FHA/VA: Yes ❑ No f g. 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-----h--------Mat ri_eVl----_______________ __ No. of compartments----I--_-- _..__Size__3_ _ X_ __.___Liquid depth____ !_r,____--_-Capacity-.--------O-d----- 4_ Disposal Field: Distance from nearest well___-------- Distance from foundation__.....lJ......Distance to nearest lot line____"S ... [' Number of lines---------- _________Length of each line__---_-_'7�S__--_:.__._.Width of trench---------- Type of filter material ------- epth of filter material--------- k-------Total length--------------- J______________._.___ Seepage Pit: Distance t® nearest well------ ----Dista from fatfndation-------- _v__ Distance to nearest lot like___ _ Number of pits._.-_-/--------------Lining material. S' e: Dee�r1�_ ?X__s __.___Depth________/V---------------- Cesspool; Distance from nearest well________.___..__Distance from oundation--------------------Lining material____.__.____.__________________. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-.--------------------------gals. ,P Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____--__---_--__-___-_-_________________- ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------- •--------------------- Remodelingand/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 rx(es a regulations of the San Joaquin Local Health District. (Signed)_........ J1 -�--- ----------- (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 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ------------- --- - --------- DATE----------- ---- ----�---4C7------------- REVIEWEDBY----------------------------------------- --------- --- = ----------------------------- DATE------------ ----_------ -----------jS---------------=-- BUILDING PERMIT ISSUED------------------------- ------------------------------------------------------------- DATE------------------------_------ Alterations and/or recommendations------------------- ------------------------------ -------------------------------- ------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------•---------------------------• -------------- -------------------------------- --------------------- ----------------------------------------------------------------------------------------------------------- ----------={------------ FINAL INSPECTION BY:.. t�'c_ Date.-J-" '- `' ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 FY.CO.