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APPLICATION FOR SANITATION PERMIT Permit No. __ Z_ ___ ------ (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 N% 549. JOB ADDRESS AND LO ON--------- - -----•----- Owner's Name _ _- ------- -- -------- Phone------------------------------------ . ------------ ------------- - --------------------- Address-------------.........L_l---1J------------------------- ------- ---------------------------------------------------•---•-----._...----------------•- ----------------- Contractor s Name-_ �. - �� --- = -jam ' Phone.. (�. 6a Installation will serve: Residence [7f Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms _�;; —Number of baths __-__- Lot size ------ ___________________.__._ Water Supply: Public system ❑ Community system ❑ Privateer 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 a New Construction: Yes ❑ No [3111 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is-available within 200 feet.) Septic Tan D•st�np from nearest well_________________Distance from foundation--------.----_-_--Material-____-_-_---_---___•------__.._--_-_-_________- ❑ No. compartments--------------- ----------Size----••- ------------------------Liquid depth------------ ----------- -Capacity-•---------•---------- Disposa3 Field: DiFcet f F-1 �/P�Nury, nearest well_________________Distance from foundation________._._______.Distance to nearest lot line----------------- mber o mes-----= --------------------Length of each line------------------------------Width of trench----------------------------------- Type of 'Iter material------- -----------------Depth of filter material--------------- ----Total length-------•-_--••-------------_.-_-•---..---- Seepage Pit: Distance to nearest well- /0ZF- ---___Distance from fo da tion _f ....... to nearest lot line___ Number of pits------- -------------Lining material--- meter----J ......Dept h-----e�--------_-_-.-_-_-_-.- Cesspool: Distance from nearest well------------------Distance from foundation--- ----_-._____..Lining material-------------------_------__----_-___ ❑ Size: Diameter--------------------------------------Depth_----------------- - -----------------------------Liquid Capacity----------------------------gals. ill Priv Distance from nearest well-----------------------------------------------.-Distance from nearest buildin 4 ❑ Distance to nearest lot'line--------- ----------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)--- -------- ---------------------------------r------------------------------••----------------- --------------------•----------------------------------- C ----------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- 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. (S''gnedB)Y••_ - -1- 17 �"'fE ?<- 1/I (Owner ner and/or Contractor- -----------=--------------•----------- r `f/ ------• -----------------------TitleJ (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�---------------------- -- - -------------------- - --------------------------------------.: DATE51—`1 ---------------------------------------------------- REVIEWEDBY =- (\ --------------------------------------------------------------------------- DATE---- -------------------------------------------------- BUILDING ------------- ..BUILDING PERMIT ISSUED------------- ------------------------------------------------------------------------------------ DATE------Rf ---------------------------------------------- Alterationsand/or recommendations:------------------------------------------•-- -----------------------•------•---------------------------- -----•--------------------------------------- ---------------------------------------------------•---------------------------------------------- ------------------------------------• -----------------------•----••----------------•------------------------------ { - - ---•--------------------- --------------•--------------------------------------------I------------------------------------------------------------------- -••-------------------------------------=------- -•----- ------------------ ----------•------•-------------------------•-•--•-------------------- ------- -•-------- •---------•---••------- --- ----------------------------------•--------•---------------`---------- •- ------------------------------------------------------------------------ II FINAL INSPECTION BY:.. ----- ------- -- s ---------------- -- * Date. --�--------�._r__��_rSJ_----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Strae+ Stockton, California Lodi, California Manteca, California Tracy, California FS-..-4—lm - RA„;4 wainn