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t APPLICATION FOR SANITATION PERMIT I Permit No. .....7_73f7- (Complete in Duplicate) �( } Date Issued Applica-ion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County ' rdina ce No. 549, JOB ADDRESS &Z.A4 CATION_ --0- �,.----- - Owner's Name _ �" -:.---- ---• ---------------•-- -------------------------------- Phone --•--------_-- Address _ + ----------------------------------------------•--------•-•----------------------------_---------------------------•------•--•---- ------------------------ Contractor's Name--- •--- - ----- • --------------------------------------------------------------------------------------------------------•-----•--•-- Phone-----_--- •----------- --------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ________ Number of bedrooms -------- Number of baths -------- Lot size _-____________________________________________ Wafer Supply: Public system Community system ❑ Private ❑ 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 ❑ No ❑ New Construction: Yes [] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if public sewer is available within 200 feet.)r i Septic Tank: Distance from nearest well_________________Distance from foundation-------------------.Material-___.____._.._________.________-----.- ---------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--- -----------Capacity----------------------- Disposal Field: Distance from nearest well................Distance from foundation----------------....Distance to nearest lot line_______-_______- ❑ Number of lines-----------------------------------Length of each line----•-------.------------------Width of trench----------------------------------- Type of filter.material_ ___._____ . Depth of filter material----------------------- length---------------------------------- L..__., l__ _. See pa Pit: Distance to nearest wel _Distan ' frorin foundation---------_----------Dist nce to nearest lot linM/� Humber of its___.__.__r__._._._.___Linin materi Number P ! 9 -- -.__ _�-._ _size: Diameter------- ---- -Depth------/-Z------------------- Cesspool: ----------------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------ - -=--- -- ------- - ------ ---------------------------------------------------------------------------- 4., Remod mg and/or repair'ng, (des ibe}' ' --- �•- -- ... ----------------- -- - ------------- �_ _ = --- �-f ----------------------- _ _ ----- -'------------------------------- I hereby certify that I have pre red this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an regulations of the San Joaquin Local Health District. (Signed)-------•---:-:-''---"------------' --=-�- ----- ---- --------------------------------------------•------:-----------------------------.[Owner and/or Contractor] 5 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_________________ _ REVIEWEDBY P-- ------- - -------------- -- --- ....... --------------------------.._... DATE- --------------------------------------------------- - BUILDING PERMIT ISSUED. , DATE -- •----•------ -- ------------------------- ---- -- Alterafios and/or reco menda+ions:__-------------- ---------- -- ----------•-----•-------------------------------------•-----------•------------------------------------------------- ---------- ri - ---------- -•••---•.•. -------------------------------- ---------------_ . .- . '-�''-fir - - ------ _ - ------------------------------------------------------------------------ --------- -::_:::::::::::: ----- --------------------------------------- -------------•-------------------------------------- -•--------------------------------------- ---------------•---------- FINAL INSPECTION-BY: - Date - --------- r+ - SAN JOAQUIN LOCAL HEALTH DISTRICT . 130 Soufh American Sfraof 300 West Oak Sfreef 132 Sycamore Sfreef Bio Norfh "C" Sfreef Stockton, California Lodi, California Manfeca, California Tracy, California ES-9-2M -446 AT.... -4