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�S r q v 1y \ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) y Application is hereby made to the San Joaquin Local Health District for a permif to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION___A�74�______ Owner's Name________/. q Phone Address-------------- - K e------------------------------------- Contractor's Name = ----- - --------------------•-----------------------. Phone..--------------------------------- Installation will serve: Residence I A'partmentyHouse�❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ _.ter •- ' � Number of living units: __/-_ Number of bedrooms _�� Number of baths __l___ Lot size __ --X._/se /__________ _ ___ Water Supply: Public system ff-60mmun•ity system ❑ Private ❑ Depth to Water Table 'Wf. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan [❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ® SHA/VA: Yes ❑ No [j-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we4-----------------Distance from foundation--------------------Material ______-------_.___.____-.__-__.____._.________. ❑ No. of compartments--------------------------Size............---------------:_..Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well____. ---Distance from foundation___/e -----Distance to nearest lot line---�_�_�_-. Number of lines___-_--____-_________________.__Length of each line--------- ............Width of trench------_V�______-_______ Type of filtermaterial_,�lo__� -Depth of filter material__-A��!________Total length_____-____' o `_'___________________ Seepage Pit: Distance to nearest well-----_-- ----------Distance from foundation----/_.z_-------Distance to nearest lot line----%J- ----- Q Number of pits--"--/--------.___Lining material___._49Z_1__�i-_Size: Diameter---%AJ-----------.Depth --_oZ- --------------------- \ Cesspool: Distance from nearest well-----------------Distance from foundation--------------______Lining material___._---._____._____.___-_._________ ❑ Size: Diameter------------------------- ----------- Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. 1 Privy: Distance from nearest well---------- ---------------------------------------Distance from nearest building--------_--------------------------------- ❑ Distance to nearest lot line-------------------------------- ---------------------------- Remodeling and/or repairing {describe}: �- 1 - '-------------- 1 -------------------------------------•--------------------------------------------------------------------------------------------- - ------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------ ------------- 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) ----- � __ - / � - ----------------------_/- - Vr Contractor) By:------------------------------------------------------ 6� ---- Tale 1aCr� �'-------------------------- (Plot plan, showing size of lot, location of Aem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By--------------------------- -- ... ------- ---------------------------------------- DATE.--------- --- ------- -- - -------------- REVIEW! D BY �, DATE----- BUILDING PERMIT ISSUED------------- - - -- -- --------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:------------------------------------------------------------------------------------ -------------•----••-------------- y ------------------------------------ ---------------- Nw ------ - ---------------------------------•-•----------•-----------------------------------------------------------------------------------------------------------------------•---------------------------------------•--------------- --------------------------------------- FINAL INSPECTION BY: -------- Date - --------- .. j` 1------- k SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814.'NorA "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I . ES--7-21x1 Revised 1.57 F.P.CO. t