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APPLICATION FOR SANITATION PERMIT Permit No.`s (Complete in Duplicate) Date Issued .d =- App ication 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 witth' County Ordinance No. 549. JOB ADDRESS AND LOCATION ------ !-_ 4r? -`---- W_._._%,-�.�- Owner's Name ------------------------ ---------------------------------------- Phone --------------------- ------------- Address. ------------ 3� Address-/D�-- —1.7 -/ at- - -- -------------- ............................................................. Contractor's Name ------------------------------------------------------------------------------------------------- -------------------------------------------- Phone .................................. Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r — i Number of living units: _/____ Number of bedrooms ___r_' Number of baths -Z... Lot size ...... 7jf ...... __ %__________________ Water Supply: Public system ❑ Community system ❑ Private Q Depth to Water Table ----- - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 3 Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 4 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.__,5Q__---__Distan a from ffouncla ion_.__./__�_--___.Mat'efiRl__..1!� C1. Z''_ ______�___. No. of compartments_______ --______________Size _-57X,�____/r-_'__Liquid depth __.._._`-____________-Capacity --- 1?1�___..__ Disposal Field: Distance from nearest well_ -��----- Distance from foundation... Distance to nearest lot li e_. S_:`''? i Number of lines__________ ____._. ______ ___ Length of each line____--- -'� -- Width of trench.__-�_ X.' K. g ft rr-------------- Z Type or filter material__.._ _-----..Depth of filter material ---- /_______.__Total length ------------ _______________________ . Seepage Pit: Distance to nearest well ---------------------- Distance from foundation .................... Distance to nearest lot line ----------------- 171 Number of pits______________________ Lining material ----------------------- Size: Diameter ----------------------- Depth --------------------------------- Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material ----------------- ,------- .__......... r Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------ •------------gals. Q Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building --------------------------- ..______-___. ❑ Distance to nearest lot line ----------------------------------------------------------------------- --------------------------------------------------------------------- Remodeling and/or repairing (describe)____________________________________________________________ ----------------------------------------- ------------------------------ V ---------------------------- --------------------,------------ ----- 3D ---------------------------------------------------------------------------- h ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify the+ I have prepared this application and that the work will be done in accordance with San Joaquin County Q ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) --------------- ------- ------------------ ----- (Owner and/or Contractor) . .2/ = ` %"` "---------------- By:-------------------------------------- (Title) --------------------------------------- - ---- -- --- (Plot plan, showing size of lot, location of system in relation towells, buildings, etc., can be placed on reverse side). C' FO�MPT USEQNLY / p APPLICATION ACCEPTED BY-.-- - DATE------- /p _.._>.,77 -- REVIEWED . -----REVIEWED BY------------------------------- ------------- ----------------------------------------------------------------------------- DATE ..-------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------------- - ------------- .----_.. -----. DATE ---- --- -- ------------------------------------------ Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------............................... ------------......----------------------------------- ------------------------ - ---------------- I ----------------------------------------- ............... - ................................ - --------------------- --------------------------------------•-............. • FINAL INSPECTION BY: .............-- Date----------- bi--=� ---------------------------------- -------------------- SAN --� -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES—%--2MM1,0.,52 Revised W-2100 300 West Oak Street 132 Sycamore Street 814 North- "C" Streei Lodi, California Manteca, California Tracy, California