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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �y ;� 5 Date Issuedj_ /4_/_ lj � I a pplicafion is hereby made to the San Joaquin Local Health District for a permit to construct and stall the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI N_______ r - ----------------- --- ----------------------------------------------------------- -Owner's Name--------------------------- - - ------- ----------------------------- Phone------------------------------------- Address--' ----------------------- Address -------------------------------- - --------- ------ �' ` 1 P Contractor's Name t _ �- - ----- Phone6� - { Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�_____ tuber of bedrooms _.4'_ Number of baths __ ___ Lot size ___ 7 __ _ ___- + Water Supply: Public system Community system '❑ Private ❑ Depth to Water Tabl,Q101 ft. ' Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ lay Loam ❑ 'Clay ❑ Adobe Hardpan ❑ ~;•' Previous Application Made: Yes ❑ No New Construction: Yes �o ❑❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if publicOew, 1s available within 200 feet.) SepticTa Distance from nearest we;tAY-g__ tanee from foundation_1_-_ ________.M�att r'aL____ C�-- ______ _______________ �_. ❑i/ No. of compartments__- �q_____________ ___ �/ _ ___Li Liquid depth Ca acit _ n cf1 q p +'°a-�-� p y--- i !!{{yy Disposal Fi : Distance from neare. well_ d' ]stance from foundation__,[_7'_ ____Distance to nearest lot Jine___ ____._. 1 ❑ Number of lines_____________. Length of each line--- _t0_ _. ___ ----Width of trench_ _ Type of filter material_ ►1_I_____ -_ -_Depth of filter material_____ __ ______Total length______ , _______________�________ Sgepage Pit: Distance to nearest well----------------------Distance from foundation__________________Distance to nearest lot line___________._____ ❑ Number of pits--------------- ------Lining material----------------------.Size: Diameter-------------- --------Depth---------------------------------- Cesspool:. -------------------------------Cesspool:. Distance from nearest well-----------------Distance from foundation_______________ Lining material-----------------------------.__---_ v ❑ Size: Diameter-------->-----------------------------Depth----------------------------------------------------Liquid Capacity------------------ ----gals. _ Privy: Distance from nearest well___________________________________ ___________Distance from nearest building------------------------------------------ El Distance to nearest, lot line ---------------- ----- --- --------------- --- Remodeling andrepairing (describb)______________: _ ------ --- -- .-------r------•------------------------------ - 0 -------------------•------:------------------------------------------ -------------- -- -- -- a----- ---•------------------------------------- ---------------------------------------------•- ----------------------•---------------------------------------- ' s?'°_ - - - - - -- ---- - - --- l ' ----------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law , and rules and re afions of the San oaquin Local Health District. Y 51 ned '"" _ ____ _ __ .O: ner and/ r Contractor) 4 - ------- -- --- - ---------------- By•---- ------------(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------------------------ - DATE----------------___--- _ __-- REVIEWED BY- ------- - ---------- DATE------ -- j BUILDING PERMIT ISSUED----------------------- - ----------- DATE ; Alterations and/or recommendations:------- --- s�? -� t- -----•------- ------------ -------------------------------- ' - ----------------- ----- ----- ----- -------- -- ----------- -------- -------------- --------------------------- ------- ---___- . - --- -- ----- --------- ------ l FINAL INSPECTION BY:-------- o1__ l �Ia �4 "�� ---------------------------- Date ------ - ------------------/------------------------ -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street I i Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100