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/ 1� APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicate) I 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 No. 549. JOBADDRESS AND�LOCATION ./... --------------------------------------------------------------------------------------------------------- Owner's Name--J ! ` ' ---------------------------------------_ Phone------------------------------------ Address------- -----------------------------------------------------------••----------- -------------------- Contractor's Name-- ----- - --_--__---- Phone_�7 Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-( Number of bedrooms _-Q—Number of baths j___ Lot size __Q'*^�!_____-X----/---- _# _________________ �. Water Supply: Public system a--j--ommunity system ❑ Private ❑ Depth to Water ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe L—j---marapan Previous Application Made: Yes ❑ No g---New Construction: Yes ❑ No E — TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:r, Distance from nearest well------------------Distance from foundation--------------------Material------------------------------------------------- No. ________________ ________________-_______- No. of compartments -------- -------- Size--------------------------------Liquid depth--------------------------Capacity------- ------------•-• • isposal Field: Distance from nearest weli-----------------Distance from foundation---------------------Distance to nearest lot line-----------------1" Number of lines-----------------------------------Length of each line-------------_----------------Width of trench-----_----------------------------- 00 Type of filter material------------------------- of filter material----------------------- length-------------------------------------- See __._-----____________________________.___ Seepa e Pit: Distance to nearest well ------Distance fr m #o ndation-----f__Q_ ._.Distance to nearest lot line - ZL Number of pits-.-.-E -------------Lining material__ _- _ ___-_Size: Diameter, _�_�-___-____Deptn_. .___.�.__ --_F-- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- El ______❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Owl Privy: Distance from nearest well __-__.------------------------------------------Distance from nearest building------------------------------------------ 0 ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------- ------=--------------•---•------•---------------------------- ----•---•--------••------••----=--------------------••- -------------------------------------------------------------•-----------------------------------------------•------.-I--------•--------------•--------------•---•----•----•---------------------------------------------- ---------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------- 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)-.�. - - ----,---- ------•----------f-{6�'Rer e++eFf�i�Contractor] By i - '7 -- ---------------------------- (Title) (Piot plan, s swing 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-----------•- r 2- ---------------------- - V�- 3 REVIEWED BY DATE --------- ------------------------------------------- BUILDING --- -- BUILDING PERMIT ISSUED---------- -- --------- ------------------------- I-----------•--------------------------------------- DATE---------------------- -------------------------------------- Alterations and/or rec mendations--------------------------------------------------------------------------------------------------- ----------------------------------------------------------- --------------/ ---- ----------- J' -----------�------- --- - -- ------------•�� C i{ ------------------------------- --•---- .-------------------•---------------------- -_--... ---------------------------------------------------- -------------- ----------------------------------------- -------------------------------------------------------------- ------------- ----------- --------------------- ---------------------------------------------t--------------------------- ------------------- r FINAL INSPECTION BY: ----------- ------------- Date---/ VVV 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 145446 ATWC] D 12-54