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\<ijAPPLICATION FOR SANITATION PERMIT Permit No.dX ....a--_3 (Complete in Duplicate) / Date Issued Applica{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 549 JOB ADDRESS AND ATION------------------ - � �.r� - ------------------ Owner's Name. �� N-t -- --- ------- --------------------- --------------------- ---. Phone-/-"/ Address----- •-- - ---------- - ..... ------------ --------------------------------------------------------- Contractor's Name---------------- --------------- ---- -. --- --- --- - --------- -------------------------------------- ---------•----------- Phon ------- y{� Installation will serve: Residence 2---A--partment House [] Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ r j i Number of living units: _- ---- Number of bedrooms -_� Number of baths ---/_ Lot size ---- Wafer -_Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table y�ft. Character of soil to a depfh of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes E] Noy New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Tank: Distance from nearest well- --------------Distance from foundation_-.-------------.--.Material--_-_------._------. -------_...----- .No. of compartments- ------------------Size--------------------------------Liquid depth--------------------------Capacity-•--- ------ 4pti sp sal ield: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines----------------------.------------Length of each line---------------.-------------.Width of trench----------------------------------- Type --------------.-- --_Type of filter material-------------------------Depth of filter material-----------------------Total length---------__-__---------------_-.---_----_ Seepage Pit: Distance to nearest ell-.2244).WDistance from fo ndation---L.Q--_--_--.Dista��e to nearest lot line-_s2�- ®/ Number of pits..-.--...........Lining material__---Size: Diameter---;?g--____._---Depth--. --5.--_ --------------- Cesspool: Distance from nearest well-----------------Distance from foundation---.------------ ----Lining material-------- 0�'� ❑ 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 County ordinances, State laws and rules and regulations of the San Joaquin Local Health District. (Signed) ..... -- wner and/or Contractor) By:--------------------------- -��' -----�- ---- �?`- ------(Title)---- - -- ............ ---------- -- ---------------- (Plot plan, showing size of lot, location of system ' relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ - ----------- -------------------------------------- DATE a REVIEWEDBY- - --- --- --------- ----- ------ ------------------------------------------------ DATE--... BUILDING PERMIT ISSUED ------- ------------ DATE.- Alterations ATE.Alterations and/or recommendations: ----------------------------- ----------- ----- ----- ---------------------------- \ - -••------------ -- -.- - : :::::::::::::::::::::::::::.. rte- --�--------..___.--- - ----- -�-- -- - •• -- --------------------------------- j---- ------------ ----------------------------------1___1--------------- FINAL INSPECTION BY:- ----- Date J T- - 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 145446 ATWC00