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APPLICATION FOR SANITATION PERMIT Permit ` (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 LOCATION s//o- 1di ► "` N -------- ------------------------------------------------------- - ` Owner's Name------- D--------- ---------------- Phone---3 ,3 ------- Address--------------------------------------7-_A_ 1.�..-_------------------------- --------------------------------------- ------------------------------------------------------------------------------ Contractor's Name------------------------------------------- ----------------------------------- ----- Phone ------ Installation will serve: Residence N Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ - Number of bedrooms __ _ Number of baths ---/--- Lot size _____ .Ci__-X__1_ _'S__ -------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ 4sravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobes Hardpan.[ + Previous Application Made: Yes ❑ No (f New Construction: Yes' ' No ❑ 4 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tapk: Distance from nearest well____________'___Distance from foundation---------------------Material______________________________________________ jDA41No. of compartments------------------------Size-----•-------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well--------`-- Distance from foundation_-_--3_p------Distance to nearest lot line----J__0-_f. [4 Number of lines______________j____a_¢¢,�_ Length of each line______-�_C.t_'-----------Width of french-____�_ '!_____.________ Type of filter material---J_Z2 !L_k4_kDepth o i er maDiln . ___L_ '1___iTotal length---------3-a--_______________�__ Seepage! Pit: Distance to nearest well-------- ce from ,foun _______3_d.__.Distance to nearest lot line_______ _� Number of pits__________l--------Lining mater - � Diameter_.__--d '� Depth______ _ Cesspool: Distance from nearest well-----------------Dista - --------__------_.- 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):-------------- V 1` Q !' _. ------------------------------------------------------------------------------ ------------- -----------------------------------------------------------------------------------------•-- ----•----------------------------------------------------------------------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Afe ws, nd.rule and regulations of the San Joaquin Local Health District. (Signed).--. = (Owner and or Controctor]r By:--------------------------------------------------------------------------------------------------------------------------- ------(Title)------- ----------- ------ ------------------------ (Plot plain, 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----- ---- REVIEWEDBY--------------------------------------- -f/"fvJ -------------------------------------------- DATE- -1 -----S-------------------------------BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------ - ---------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------•----------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------------------------------------- ------ ------------------------------------------ --------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- 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 E5-9-21VI 8.51 Revised W-2100