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O APPLICATION FOR SANITATION PERMIT Permit No. ./_L............. \'y\ (Complete in Duplicate) Date Issued 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 with County Ordinance No. 549. . JOB ADDRESS AND CATION -- i--7�`f---�.U�--------------------------------------- Owner's Name----------------- 1------�------ ---- l---��--`---------- --------------------------- ---1•-------------------------------------- Phone`3.-`�_------------- Address---------- --Address---------- ---------------------------�---�--��'3......C�-I n' 1 . ------------------------------------------------------------------------------------------------------------------------ e Contractor's Name---------------•----------------��-'�-w)-A m'�-- �_.j .�_t. - - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /------- Number of bedrooms _2-- Number of baths _1____ Lot size _____- _1� OL - Water 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 21 -i9'erdpan ❑ Previous Application Made: Yes Ea--I�o ❑ New Construction: Yes ❑ No ©--1HA/VA: Yes ❑ No L,— 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-----------------Distance from foundation--------------------Material-__--_-__-_-_-..-_._----__-___--_-_.--_--__-_.._. k�� Y No. of compartments--------------------- --Size---------------•----------- Liquid depth-••-----------------------Capacity-------•-------------- ! r Disposal Field: Distance from nearest well- Distance from foundation.__) Distance to nearest lot line�----------- -,-A -_-,-AE� umber of lines-------- �•- -----------__-_-_-__Length of.each line-------- _-__{-i___-_--:Width of trench 1_�----------------------- pe --- -------------- pe of filter ma terial_____YfZ ''� _Depth of filter material___._l�_.._______Total length______ %S*�___f Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-------------- ..17U k11 _--____-_--_../-7Uk1, Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-_______________-__.-___---__- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------------------_ k ❑ Size: Diameter----------------- -------------------Depth---------------------------- ------------------Liquid Capacity_--------------------------gals. Priv Distance from nearest well _---------------------------------------------Distance from nearest building ❑ Distance to nearest lot line----------------------------------------------------------------------- •--------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------•---------------•--•------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that 1 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)____________________________ y---- (Owner and/or Contractor) -- ------- ------------- -------------------------------- B . ------------------------------------------------------------------------------- (Plot --------------- 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 �' G Y�- c,"�` ^_ DATE + REVIEWEDBY-------------------------------- -------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations-------------- -------------------- ---------- ---------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------•-------------------------------------------------------------------------------•--------------•------------------------------------------------------ ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------.......................... ------------------------------------- ------�------------ --------------------- --------------------------------------------------------------- FINAL INSPECTION BY: ---------- --- ----- Date < 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 ES-9-2M Revised 1.57 F.P.CO.