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APPLICATION FOR SANITATION PERMIT Permit No.�'j.... (Complete in Duplicate) rp a 11 Date Issued Applical'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, t . t JOB ADDRESS AN LOCATION_._ 1 - ,1�/� �- Owner's Name----- - T Ph e f `til Address---- _ --- • Contractor's Name --- ----- -------- -- � ..� .. i - xK�= � � ,c ►s Phone_ I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-.- Number of bedrooms _/_. Number of baths _/--- Lot size --_-.,I,, _-----_--_-,•--_-----._ Water Supply: Public system ❑ Community system ❑ PrivateK 'Depth to Wafer Table_A�_ ft.' Character of soil to a depth of 3 feet:.#Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑' Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Ye No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w _(No septic tank or cesspool permitted if public sewer is available within 200 feet.) % �..,,�,.�- ..— - -_. .:: 46 - .,,.ter ,. ! :.�.�...�- .....,,,,,,■,r,�. .- ::� ^ Septic Tank: Distance from nearest well-��-------Distance from f8unclation__=;/11 ---_--.Material_,._ _............:.......... No. of compartments--.s�._._-._-------.Size-X r��_Liquid depth_ .-. ___3.r_ ._Ca acit ___.____ dp+ 14 � Capacity �--------- Disposal Field: ' Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line----------------- Number of.lines----/----------------------------Length of each line------Zq__. -------------Width of trench__ -----_ - Type of filter material-------------------------Depth of filter material-----------------------Total length-----_---------.---•---------------------• 1 Seepage Pit: Distance to nearest well----,7J-----------Distance from f ndafion__,��__ -.-__.Distance to nearest lot line....-----_- Number of pits.__-_ - - Lining material' _ Size: Diameter ��_...__-De th._._ ' v p ----------------- Cesspool: Distance from nearest well-----------------Distance from foundation----------------------Lining material------__---_---__.._--__---- .------ I' �„ ❑ . :. a. _ S_iz�eT:� Diameter-------------------_-_-�-----�-.------- ----•.-D-e -------------= ---_---•--------------- -� -.----- -----.____.___.gals.. - Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- . ❑ Distance to nearest lot line ------------------------------------------------------------------------------------------- Remodeling and/or-.repairing (describe):_ _ -__ ------- ------•----•-----------------•---- --------- -----------•----------------------------------•-----------------•--------------------•------------ ------------------•--------------------•---------------------- .. -----------------------------------.-..._-----------•---------------..-._.. --------•-----•-------------------------•-------------•------------------------ 1 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 laws, and ales and re ulations of the San Joaquin Local Health District. i ------u.------ _____(Owner and or Contractor) _ (Signed, By------------------- .: - ------------------- ---------------------- -=- _ (Title; � (Ploi`plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p ked on revers side i I - 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ---------------•----------------------------------- DATE---� ...-'S-- --- REVIEWEDBY------------------------------ ------------------------------------------------ ---------------------------------------------- DATE------------------ BUILDING PERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE----- Alterations and/or recommendations------------------------------------- ------------------•-••------------------•-----------------•----------------------------------•--- -----------------•-•------•---------------•--- ------ ------ ------ -----------------------------...---------------------------------------------------•--------....-------•-•---------•-----------•------•-- ---•-•---------------• -------•----------•--------•----------------------------------------------------------------•-------------- -----------------•------------------•---------- ---------------------------- -- ----------------------------------------------------------•------------ ---------------------- -----------•------ -------------------------- --•--------------•------ a f FINAL INSPECTION BY: --------- Da+e - 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 E5-9-2M ; Revised W-2100 f