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APPLICATION FOR SANITATION PERMIT Permit No3_ 6-____2' (Complete in Duplicate) J Date Issued . -_____-___`5- _3 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 A LO ATION ----------- � - r Owner's Name ,"_> -------- Phon - -- ----- ..e r ^ Address } }' = ----- ' , 0I---' -------- ----C-AL—AT Contractor's Name------------------ --- ------ - ---------------------------------------------------'Zt' ----------- Phone......---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: --- Number of bedrooms I--- Number of baths _�_ Lot size ----- Water -_��_�___ Water Supply: Public system ❑ Community system ❑ Private X De th fo Water Tabl _�ol� Character of soil to a depth of 3 feet: S nd Grave! Sand Loam Cla Loam Clay Adobe Hardpan p ❑ ❑ Y Y ❑ Y ❑ � r_R Previous Application Made: Yes ❑ NoR New Construction: Yes No ❑ ,� , �,�:„s 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______________ __-_.Maierial--_--__________________-__-_-___________--_--___. ❑ No. of compartments----- -- iSize--------------------------------Liquiidd�de th:-I--------------------- Capacity------ - ------- Disposal -----=Dis os I Field: Distance from nearest 17 0--.Distance from founclat- ___w4 Distance to neare t 'n Number of lines---------- _________ ____Length of each line-_ .__.Width of trench_ Type of filter material__ _ __ Depth of filter material Total length._____ Seepage Pit: Distance to nearest well_______ ________Distance from foundation_...---------------.Distance to nearest lot line--------___-___ r. . ❑ Number of pits----------------------Lining maferial-----------------------Size: Diameter------------------------Depth-----------______-------------- 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----------------------------------------------------------------------------------------------------------------------------------------------- I' Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------ -•---•-•--_-------------•-- [ -----------------•------------------------------------------------------------------------------------------------------------------------------------------------------------••-------------------------------------- -----------------------------------------------------------------------------------------------------------------------------•--...-.--------------------------------.-------------.--•---------------------------------- -------------- --------------------------------------------------------•------------------ -----------•----•----------- ----------------------------------•-------•---------------------- I here6y certify that I have prepared this application and that the work will be do a-in actor ante with San Joaquin County ordinances, State lawjoNd rules and reguVins. of t Joaquin Lo aloHealth is i (Signed) - -- --- -- --- -- --------------------- {k� Contractor) +I 1� I By:----------------_------------------------ -----A --------------------------------------------------(Title)---! ?Wo ---------------------------- (Plot plan, showing size of lot, location of ystem in relat n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____/�; (' _�__ - .�._..--�,-_�i•"j�1��:- - DATE-------'�--6-=--s-------- --- -- --------------- REVIEWEDBY---------------------------------------- ---- ------------------------------------------------------------------------------ DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------- ---------------- DATE--------------------------------------------------- Alterations and/or recommendations------------ ------------- ----- ------------------------------------------------------------------------------- ------------------------- -------------- ------- FINAL INSPECTION BY: Dat SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfroe+ 300 Wes+ Oak Sfree+ 132 Sycamore Sfree+ 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100