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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate] ^_. Data 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. JOB ADDRESS AND LOCATION------- O ATION------ ✓- ,----- ..._ ----------------"-----°----------------------------------------•-----------•--•--- • Owner's Name------- e ----- -------------- ---- ------- Phone------------------------------------ Address-............... ---� -------------- ---•---- --- -- ,-•------------------------------------ ' .h Contractor's Name-----4 -•• �-- GL1 - Phone 4-,-= Installation will serve: Residence,®. Apartment House ❑ Commercial ❑ Trailer -Court ❑ Motel ❑ Other ❑ Number of living units: _l____ Number-of_bedrooms __. Number of baths _Zttot size _______ __________ Water Supply: Public:system Community system`❑ Private ❑ Depth to Water Table _..VF ft. t Character of soil to a depth of 3 feet: I Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe JHardpan ❑ Previous Application Made: Yes ❑ No,& New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Septic Ta :. Dist nce from nearest well---------------- (Distance from foundation.-------------------Material _-_-___:-_-_-_-__-__-_.___________--_..__-____. compartme nts-------- ---------------Size----------------------------:--:Liquid depth--------------------------Capacity----------------------- Disposal Field' Distance from nearest well-________________Distance from foundation___-----___:___-___.Distance to nearest lot line________________ er of .lines---------------- ---- - - -Length of each line-----------------------------.Width of trench-.------------------- ------ �A� ! of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearesf�weli___ _. Distance from f ndat'on---/'b-__--�___-Distance to nearest lot line_- -.�'��______ I wp^yI� I Number of pits___-_.________Lining material_, Cmr _" :rDiameter__'__. _ _•l___..Depth_. ______________ Cesspool: Distance fi,om nearest well________________E Distance from foundation- ..----------------Lining material__._-_____..__-_"____-_-___-_________- ❑ Size: Diameter------------------------------------!Depth-----------------------------------------------------Liquid Capacity----------------------------gals. Privy:' Distance from nearest weT._._`---'----------------------- _____________Distance from nearest building._ _-___.-_-__-________-_'-__-__-. ❑ Distance'to nearest'lot line--------------------- r ------ --- .. . - ------------------------ Remodeling ----------- --------Remodeling and/or repairing-(describe)_---------------------------_------------------------------------------------------------------------------------------------------------------------------- -------------- s --------------------------------------------------------------------- !hereby certify that 1-have-prepared this applica+ion and that the work will,be done in accordance with San Joaquin County ordinances, State s,: nd rules and.regula+ions of the San Joaquin Local Health District. _ d (Signed)------- ---- - ----- -��-------------- - ---------------{O er.and/or Contractor) 13 ' - su ---------------------• .-(Title) ----- ---------------------------------------- . y, a,,r- (Plot plan, showing size of lot, lata+ion of sys+em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --------- ------------- ---------------------------------------- DATE------------ r--_- ---- .- ---- -- REVIEWEDBY-------------'------------------- ----------- ----------------------=----------- ------------------ - --------------------• DATE---------------------------------------- BUILDINGPERMIT ISSUED-=--------------------- -------------------------------------------------------------•--...-------•-• DATE------------------------------------------------ Alterationsand/or reeomrnjndations:----� --------------------------- ---------- ----------------= -------"e--------•-----------------•--•--------- ......... ----------------------••---------_.- { E --------------------------------------------------------•...-----------------------------•----------------------------- -----------""----------.--_.---•---•------------------- – - - -----------------------• -•------•- -- ---------- ----------------- -------------------------------------------------------------------------------••----------------------------------- i ------------ ------------------------------- ------------ --------------------------------------------------- ----------------------------•-------•-------:--------------------------•-- ------------------------------ FINAL INSPECTION BY:.':.----- ----- - ---- ------------- --w_-__-- Date--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4-2M ; Revised W-2100