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APPLICATION FOR SANITATION PERMIT Permit No. .......... (Complete in Duplicate) Date Issued ___._______�_/� Applical�ion is hereby made to the San Joaquin Local Health-District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION C` L ----f ------,qt------------------------------ ----- Owner's Name = ! a'� t3�I_--- ---------------------------•------------ ._._..-------------------------------------- Phone------------------------------------ Address � `- Ge1 / ��y ----•---..d .. �� Contractor's Name------------------ -. - / � '": :r.�-�' `' ...._. Phone---------------•-• •...---------- Installation will serve: Residence @� partment House ❑ Commercial ❑ Trailer"Court ❑ Motel ❑ Other ❑ f Number of living units: ___t_ Number of bedrooms __ _. Number of baths _/--- Lot size------ _.___. _. '________________________ r Water Supply: Public system E Community system .❑ Private ❑ Depth to".Water Table I-K-1-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑. Clay Loam ❑ Clay ❑ Adobe gT---Hardpan ❑ Previous Application Made: Yes ❑ No 52-'New Construction: Yes ❑ No TYPE -OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within"200 feet.) Septic a�nk: Distance from nearest well_________________Distance from foundation__._:---------------Material------------------------------------------------- lxt� No. of compartments--------------------------Size----_-------------`------,__Liquid de th--.----_-----------------_Capacity Dispo Field: Distance from nearest well____._________ Distance from foundation----------:_._:......Distance to nearest lot line-_______-______- ' Number of lines------------- ------------------Length of each line------------- - ------------_Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material_.. : ------Total length__________________________________________ Seepage Pit: Distance to nearest well_. - �}` "Distance from fouPdat•on___� ____._-..D.•st nce to nearest 10 lin Number of pits...._-__________-Lining material-ACi / e: Diameter._ _„ .......Depth--- ___------------- Cesspool: ___________Cesspool• Distance from nearest well_________________Distance from foundation-._--------- --- materia l-___.._:.________._________.___-___-_. ❑ Size: Diameter.- ----------------- ----De Depth--------------- -----------------Liquid Capacity:_ gals. Privy. _Distance from nearest Weil_______________________ _.._ - n-:.-Distance fror6 nearest building ❑ Distance'to nearesf lot line---z___ -- - _ ------------=-- -•------------------------------------f----------------------------- Remodeling and/or repairing {descriE�e�: --------- - ------------•--------•-------------=------------------------•-------- ------•-------•-••----- ----------------------------------------------------------------------------------- --------------------- i - ---------------------•-- :---------------- ---- ------------- --------- •---.------------------- -------------------------------------------------------- I hereby certify that I have prepared this 'application and-that-tke work will be done'in accordance with San Joaquin County I ordinances, State laws, and rules and regula ions of the San Joaquin Local 1-16h District. (Signed) "� /F--��- �`----= - ' -��. --- .- =`=(mor Contractor) __ 13 • - '�� - --=---- Y•------------------------� :... - ----, - - - (Title) (Plot plan. showing s4e o�Aot, location of system in relation to wells, buildings; etc.,,can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION.ACCEPTED BY--------------- ----------------- ---- --- -------------------'--------=------------------ DATE---- REVIEW,ED BY ___ DATE------ ------ --------•------------------------------------- BUILDING PERMIT ISSUED------------------------------------- ---- DATE----------.-_... - `�'�-------------------------------------- Alterations and/or recommendations: -` •-•-----•-••----•------ ------t---••-•-------•----------------------- -----------•------ --------------- _ —�1 f v� rr -----------:-------•---•- ---------------------------------------------•-- ------= ----------------------- ---------------------------------- ----------- ----------------=------•-----=-------- ---•- ----------------- -- ------------------------------- v f i FINAL INSPECTION BY: � ,. -----------------------I --------- Date J_OAQUIN LOCAL HEALTHDISTRICT 130 South American Street 300 West Oak'Strset '132�Sycamora Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California '~ �S--+g 145446 nTwoon /