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APPLICATION FOR SANITATION PERMIT Permit No. ._Y�!�_Z__-____ (Complete in Duplicate) �! Date Issued :_711-40�_____ Applica}ion is hereby made to the San Joaquin Local Health District for a permit t construct and install the work herein described. This application is made in compliance wit ounty Ordinance No. 549. �. �------------------------ 4, JOB ADDRESS AN LOC TION------------------r-- -- ---------------- --------------- --------------------- --`------------------------ ----------------------- Owner's Name �3. -� 4� -'�------�---------- � - - Phon /LLn'1 _4611 - Address ---lI_-'C ^! 1 -- ---- - --------- -------- -- -- Contractor's Name____ _ I ___ '7 `- ----- -G .- __-_�'__---- ------------- Phon - Installation will serve: Residence 4--ATa rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I_ Number of bedrooms _.Number of baths I----- Lot size -- _ ________ _____ ________________________ Water Supply: Public system ❑ Community system_D Private R!f--Depth to Water Table Character of soil to a depth of 3 feet: SandGravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No %'New Construction: Yes ❑ No ,fjn�____. 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-1-1-0-r__Distance from foundation_.-l__c ---- -Matial_-_ __ ----- --- No. of compartments_____ — ( _eZ----------- ___ _ --___ Disposal Field: Distance from nearest wellj�------Distance from foundation-----j'_5--_---.Distance to nearest lot line-/40-( Ee Number of lines----------- __�.;JT-_ ength of each line_/_C_G'Z_-.f;_-.-.Width of trench__Z__S_�_________________ Type of filter material-_Z�__ _ epth of filter material-___/__'____Total length-----,f__ _p______________________ Seepage Pit: Distance to nearest well__------------- ------Distance from foundation--------------------Distance to nearest lot line----------------- D Number of pits----------------------Lining material----------------------- Diameter-----------------------Depth------------------------______ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------_-_______________________- ❑ Size: Diameter-----------------------------------Depth----- -----------------------------------------Liquid Capacity_...------------------------gals. Privy: Distance from nearest yell_____________________________ Distance from nearest building-__________-_______________-_-____.____. ❑ Distance to nearest lot line----------------------------------------------------------------------- ----------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- -----------------------------------------------------------•- ------- ------------•------------------------------------------------------------- --------------------------- k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, nd ruleand re ulations of a San Joaquin Local ealth District. (Signed)----- -- -------- ------ - ----- --- ontractor) ---- 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',,------------------------------------------------------------------------------ ------ DATA _,-:=---------------------- -------------------------- REVIEWEDBY----- ----------------------- ----rti----------------------------------------- --------------------------- DATE__ " - ---------- BUILDING PERMIT ISSUED------------ �------------------------ ------------------------- ------ DATE---- ---------- --- - -------------------------------- Alterations and/or recommendations:---------------------------------------- ---- '` ---------------------------------------------------------------------------- -------- ---------------------------------------------------------------------- ------•------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------- ----•----- ----------------------------------------••------------------------------------------------ ------------------------------------------------------ ----------------- ----- ----------------------------•------------------------- -------------------- ------------------ _------------ ------------------- ----------------------------------- -------------------------------------------------------------------------------------------- INSPECTION BY:.. - ----------------------------------- FINALDate f 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