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APPLICATION FOR SANITATION PERMIT (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 madf, in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION • ---------------- -- Owner's - Owners Name--------------�G�-1 ------ ---- -------------- ------------------------------------------- Phone------------------•----•---•---•---- Address----------------------3... 5------------- •------------ Contractor's Name------------------------ ------ ---------------------------------- ------------------------------------------- Phone--------- ------------------------- Installation will serve: Residence$ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms _�L__'_-_ Number of baths _!_-___ Lot size ------//2 G '�_ __________________ Water Supply: Public system F] Community system El Private Depth to Water Table___ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes& 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__ D.___-__Distance from foundation-----1Q----------Maferial__ 46 No. of compartments_-____- ------------Size__ _i'K 5u acX Q ___ ______- - _____ t Q Disposal Field: Distance from nearest ______Distance from foundation____60---------Distance to nearest lot line_________ Number of lines-----------�------- -------------Length of each line--------- Q_----------Width of trench---------- -q.1------------ Type of filter material_- - -Depth of filter material _.-_-_fk___._-__Total length-------------4 Q----------------- Seepage Pif: Distance to nearest well___ -------------Distance from foundation--------------------Distance to nearest lot line__._________.-___ ❑ Number of pifs----------------------Lining material-----------------------Size: Diamefer-----------------------Depth----- -------------------- �0• Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material__-_--______________--__-______-_____. �y ❑ Size: Diameter-------------------------------- -----Depth--------- ------------------------------------------Liquid Capacity----------------------------gals. I 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 rul s and regulatipxts of the San Joaquin Local Health District. (Signed -- --------------------------------------------------------- )- h�- -�- ---�-- - --- - ------------{Owner and/or Contractor) 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 Qf� REVIEWED BY----------- ---------------------------- -y__ --------------------------- ---------------------------------------------- DATE----------------- L BUILDING PERMIT ISSUED-------------- •--- ---------------------------------------------- ------------------------ DATE Alterations and/or recommendations:---------4k! 3-- -- ---- -------- --- __ ---- { � '' ,.. ---------------------------------------------------------------- --------------------------------------------------------- ------------------------- ----•---------------------------------------_---- ---- - --------------------------- ------ ------------------------------------•------------------------------------------------------------------- FINAL INSPECTION BY: - ------------------ Dete ---�--�-� — SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100