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APPLICATION FOR SANITATION PERMIT � - , /� (Complete in Duplicate) Date Issued v\ a 0 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 wit4 County Ordinance . 549. JOB ADDRESS AND LOCATION----- ------- ---- -- ------- 4 ' -/._t/�G ...- Phone Owner's Name----------- Address ---.----- . ,.. ,� ' Address--------------------------•-------, -------------•--------------------------------- Contractor's Name --------=-------=------I------ --------- Phone--,/ will serve: Residence I( Apartment House ❑ Commercial ❑i Trailer Court ❑ Motel ❑ Other ❑ � � Number of living units: I------ Number of bedrooms _"�_- Number of baths .1----- Lot size --L� -------------------- ---- Water Supply: Public'.system$f-Community system ❑ Private ❑ .,Depth to Water Table _ ft. Character of soil to a 'depth of i4eet:1 Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ Previous Application Made: Yes'❑ No New Construction: Yes ❑ No K 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------------- from,foundation___________________.Maternal______--___.._-._______-.____.-_-_-___.___-- N -------------------- Liquid de th_______________ _____ Capacity !� ❑ No. of compartments-------------------- --.-Size------------- ----------- -• q P P Y -Distance to nearest lot line_ O Disposal Field: Distance from nearest weIIY>.2.,�Jistance #rom fou da n_�' -- ", Number of lines .----- ---Length of each line_: Q --__ 7t------- Width of trench! .........................--a b" G w Total length------&_0-------------------------- Type of filter matenal_�__y__�_-__-�Depth:of filter material _.._----____---- __ Seepage Pit: Distance to nearest well_._ - - __�- Distance from foundation----___________ __Distance to nearest lot line__.- Lining material-----------------------Size: Diameter--------------- ❑ Number of pits :-------------------- --------Depth--------------------------------- Lining ------------ ---- Cesspool: [distance from nearest well-----------------Distance from foundation----------.--__-___.Lining materia---________-______--.___._.--_.____ f -Liquid Capacity________________ ❑ Size: Diameter--------------------------------------Depth........ i T g Privy: Distance from nearest well---._____--------------- .----.--------.-Distance from nearest building------------------------------------------ M# ❑ Distance to nearest lot line-------------- ----- :. ------------------------------------------------- ----------------- Remodeling and/or repairing (describe- ----------- `---------------------------------•• ---- i ' 1 --------------------- ------------------------------------------------------------ ---------------------------------------------------------••----•----------------------'------------------------------------------------------------------------------------------------- I hereby certify that�l-have epared this application and the+ the work will be done in accordance with San Joaquin County ordinances, State la s, a d rule�nd regulat'6ns of the San Joaquin Local Health District. 51 ned -r -' ----- ------ (Signed) --__-[Owner anal/ar Contractor) [ 9 ) 1 r ------[Title)---- ---- ---- - Plot Ian, showing size o ot,.location of system 1n relati Y:-------------- -------- ' [ p g y on to alis, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY } DATE J` ----------------- APPLICATION ACCEPTED BY ----._ _- ----- -- ---------------------- BUILDINGPERMIT ISSUED- --------------- ----------- - ----- ------ ------ ------ ----------- l�XTE---------------------------- ----------------------------- Alterations and/or recommendations----------------------------- ----------------------------------_1--------------------------------------------------------------- --------------------------------------------------------- ---•--------------------•-------- _ _ _____________________________________________________________________________ _ FINAL INSPECTION BY:------ -•----- Date--- .. ---.- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American'Street 3oo West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100