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APPLICATION FOR SANITATION PERMIT Permit'No, 9 7 430 . ..Y �� [Complete in Duplicate] y Date issued . -_�/S [} Applicafion 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 CATION------------ -- `-- •------ ----- - -- ----------------------------- Owner's Name .._._ - - - - - --------------- ------- Address_ �� --� -------------- -------------- Phone.---?----------------- � ---------------------------- Contractor's Name-------- -------------•----•----------------------•--------------------------•--- -•--------- ---------------------•----- Phone_ ----____ ________ Insfallation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f Number of living units: -- -- Number of bedrooms . Number of baths __f__ Lot size Water Supply: Public system Communit system Y Y ❑ Private ❑ Depth to Water Table-�sft. Character of soil to a depth of 3 feet-. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ I Previous Application.Made: Yes ❑ NoX New Construction: YeX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from.nearesr welt '-- - __Distance from foundatio ---------.►uteri I + ` i No, of.compartments-- - -- ---.._,.__Size__a�. 6—W----Liquid depth._. ' Disposal Field: Distance from nearest well r p Y Q - Distance from foundation......--___----Distance to nearest lot line----- --.... Number of lines--------- __- ._____-_Length of each --_�_---__..V1/idth of trench._-__•, - --------------- ---------- Type of filter material - - �. - r Depth of filter material---,/ / -- - -----------Total length-------Pit: Distance to nearest well , . _Distance fr m fo dation___.._ / Distance to nearest lot a Number of pits-----1--------- ining material *-Size: r Diameter------•7-- ' Cesspool [}istance from nearest well----------------- Depth --- Distance from foundation____________________Lining material :_-______----__-- ❑ Size: Diameter---------- ------------------ -------Depth---------- ----- ------- --' - ----------------------- --------- Liquid Capacity----------------- ---------9als. Privy: - Distance from nearest well-------------------------------------------------- - r D;sfance from nearest buildin ❑ Distance fo nearest lot line - g ---------------------- Remodeling and/or repairing (describe)-------------------- -•--•-------- --------------------------- ------------•------ --------• -------- f -------------- - 4 -------------- ---------------------------------------------- ------------------------------------------•----•--------------- -•------ ------•-------------------------------------------------•------------------------------------------------------------------ -------- I hereby certify that = t I have prepared this application and that the work will be done in-accordance with San Joaquin County ordinances, Stat aws, an rlips. and regulations of the San Joaquin Local Health District. (Signed)-------- ---- # ---------------------------------------- -- ----------------------------------- r w By:. --•---=--- ( 7- ----------- ------------ ., (OwnerContractor) (Title} an`d /or Plot plan, showing size of lot, location of system in relation to wells buildings, etc., can be placed on reverse si FOR DEPARTMENT,-USE ONLY APPLICATION ACCEPTED BY--- -__--_;REVIEWED BY._-__.. DATE___ --r ------•----- ---------------------------- ------------------------------ --------------------------------------- -------- DATE__-- ----- BUILDING PERMIT ISSUED______________ ' -------- -------- Alterations and/or recommendations:._---= DATE.__.___- --__-_-___ - ------------ : ---- - --------------- ------- ----- •- -------------•----------------------- -------- .-------- _____________ ____•;--------------_------- a r ------------------- x ..: ------------------------------ a � FINAL INSPECTION BY:_ ---- --- Date '` 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 l0-52 Revised W-2i40