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APPLICATION FOR SANITATION PERMIT Permit No. ___✓� + (Complete in Duplicate) Date Issued 2-05-0'70 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein d ri ed. This application is made in compliance with County Ordinance No. 549. �/�/; .d L- JOB ADDRESS AND LOCATION, Owner's Name-------------------------- , - `r -------------------------------------------------------------------------------- ------ Phone----------------------------------- - Address --------•-••------------------ ------------------------------------------------•--•---------------------------------- Contractor's Name--------------------- = --•------------------------------------------------------------------•------- Phone----------------------------------- Installation will serve: Residence Et, Apartment House ❑ Commercial E] Trailer Court [:1 Mo#ef El Other El Number of living units: J____ Number of-bedrooms ._2Number of baths _4--- Lot size ---1-Y-9 Water Supply:pp y: Publicsystem ❑ Community system ❑ Private W~Tepth to W er Table jam � __ f� �✓" r Character of soil to a depth of 3 feet: Sand [:] Gravel E] Sandy Loam lay Loam El Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes 0 NoRT-�'5ew Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publicseweris available within 200 feet.) t Septic Tank: Distance from nearest well___'' _p------Distance from foundation----ZIP-___._.Materiai_- ---------------- No, of compartments-------:2—------------Size_- -- _____ Liquid depth-------- - ----------Capacity--- --�--- from Disposal Field: --- Number of lines eare� well--_-��-P�__�'Disfance from ength of each line--atlGl�_on 4�__��DAlsdthcofttrench nearest lot lin�---�-_T�:� fYv 01 Type of filter material_-_ Depth of filter material __._ __ Total len th_._-_ __ _ ---------------- Seepage __-- Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line _________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--- -----.Depth--------------------------------- Pp I Cesspool: Distance from nearest well-----------------Distance from foundation----------------------Lining material-________--___-------________._-_-_-. ~ ❑ Size: Diameter-----------------------------------.---Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest -building_-__________._-____,_____--------_-____. ❑ Distance to nearest lot line-------------- ---------------- Remodelingand/or repairing (describe)------------------------------•-------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------ -----------------------------------------------------------------------•----------•-------------------•----------------------------------------------•------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Q I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. it (Signed)----- -------------------- --------- --------------- -------------------------------- - ---- ----------------------(Owner and/or Contractor) •------------- --------------- -:---------------------------- ---------(Titlel--=-S.�_ __k'^_C��-,: a'�__.�.. .------ , (Plof plan, showing size of lot, locaIo of system in relation to wells, buildings, etc., can be placed on reverse side). Ii FOR DEKAENT V" SE ONVi IE APPLICATION ACCEPTED BY---- --- -------------- -------- � ---- 'ATE------ �, "•~ I REVIEWED BY--------------------------------------- --------------. DATE------- ------------- BUILDING PERMIT ISSUED------------------------------------------------------------ --- ---------------------------------------- DATE - I L� Alterations and/or recommendefions----------------------------------------------------------------=----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- --------------7------------------ ---------------:-----------------------------------------•-------------------•----------•--------------------- I -----------------------------------------------------------------------•-------------•--------------•-------------------------------•------- b ------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---------- ----------------------------- Date-------- !� " r � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street I Stockton, California Lodi, California Manteca, California Tracy, California L ES-4-2M 851 Revised W-2100