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APPLICATION FOR SANITATION PERMIT Permit No,S'.�...f y (Complete in Duplicate) Date Issued-t-f). 4_�3.. j4ica+ion 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 LOCATION-----7__ 1 ------= - '---- -----( L' -- ......... --------- --- _443 3 Owner's Name.. Q ----- Phone. Address-----..Zyjf--- . I I' - ---------------------------------------------------------------------------------------------------------------------- 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 ---------------------- Water Supply: Public system 2--lclommunity system ❑ Private ❑ Depth to Water Table :!!6� 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.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material..-________-___._____________----.-_-______-___-. No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity-_------------------- Disposal Field: Distance from nearest well*j"Distance from foundation__5i�..........Distance to nearest lot line._.: Number of lines__________ _ ---------------------Length of each line_-__ ..o____.__-___--____.Width of trench-_a_';-____________-_--.___... Type of filter material__Sc_ 4C ____Depth of filter material..__,/r-__6-------Total length.......30--____________________________ Seepage Pit: Distance to nearest well24 ---Distance from foundation...,d�.'A........Distance to nearest lot line................. Number of pits------- _____________Lining materia ___Size: Diameter---3V__ Depth___--?-f`__-___----_____-___ 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-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and nt ul��atioonJns�� of the San Joaquin Lo I Health District. (Signed) w---- _ �a _� e _(O4 w rand/or Contractor) By:-------------------------- ----------------------------------------(Title---- ---- ---- ------- (Plot plan, showing size of lot, location of system iry4lation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY j --------------------------- DATE----------------.-\--'---ir-----��l--------- REVIEWED BY ----------- --------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------................. Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- ------------ -------- ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:.--------.Ll `------------- ...... 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 W-2100