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APPLICATION FOR SANITATION PERMIT Permit No- ___ `_�v. (Complete in Duplicate) 3 y Date Issued --------�..�5-- Application 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-------------------- / �j Owner's Name------------------------------•----------------------- [ _a.-_ _ ------------------------------------------------ Phone_.e--:TAO..... Address------------------- ?'? Contractor's Name-----------------------------------_------ Aa I�- ► �^ �-e`7.;f y` Installation will serve: Residence'K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedrooms _,fit___ Number of baths __L__. Lot size ._ oeA-1-00----------------____ Wa+er Supply: Public system Community system ❑ Private ❑ Depth to Water Table,.,40 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla Loam ❑ Clay ❑ Adobe CR Hardpan ❑ Previous Application Made: Yes ❑ No;p�._ New Construction: Yes ❑ No >� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SSeepttiicCTonk: Distance from nearest well_________________Distance from foundation--------------------Material_______-____-_-_----__.________________________. F., I11'1!Ct No. of compartments--------------------------Size------------------------------..Liquid depth--------------------------Capacity----------------- ---- Disposal Field: Distance from nearest well------------------ from foundation--------------------Distance to nearest lot line------------ �A -millnG Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------N Type of filter material_______________________Depth of filter material-----------------------Total length___________________________- Seepage Pit: Distance to nearest well_N O&FK_____Distan�c�q�ff fo ndation_,1146_ _____-Distance to nearest lot line_sy________- Number of pits_____ _____________Lining materiah ��_-Size: Diameter---,,��_�-_____.Depth__.,-49 _______________ Cesspool: Distance from nearest well_____________ Distance from foundation-------------------.Lining material__________--________________________- ❑ Size: Diameter--------------------------------------Depth-------------------------------------------- -------Liquid Capacity--------••-----•------------gals. Privy: Distance from nearest well-----------------------------__...�,__,,__,,.Distance_from nearest building------------------------------------------ El Distance to nearest lot line--------------------------------------------------------------------- ---------------------- RemodRemodeling eling and/or repairing (describe):----------------------------------------------- --------------------------------------------------------------------------------------------------- ------------------------------------------- --------------------------------------------------------------------------------•-------------------------------------------------------------------------•----•---------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. (5i ned i g )------ --'-f 7= + f c' (�Con+rector} - (Ti+le) J)1�!" _fQ R------------------ �Y --- (Plot plan, s ng size of lot, location s stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ______ _ -------------------------- ---------------------------------------- DATE _-- -------- ------------------------- REVIEWED BY-------------------------------- ----------- DATE BUILDING PERMIT ISSUED--------------------------------------••-------------------------------------------------------------- DATE------------------• ----------------------------------------- Al+erat'ons and/or recommendations----------------------------------------------------------------------------------------------------------------------- - -------------- ---- -- -- ------- -- -------- -:---"-�---- ------------- ---- ------ -------- - ------- - - --- --- -- ------------- - ----- - - ----- - ------- --- ------------------------ ------------- -- - --- ---- - --- -- ------ -- --- - ----- - FINAL INSPECTION BY:__ ---------I-------------------------------------- Date------------ --- - ------------------------- SAN -w-- -_ --------_SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Stree+ 814 NorA ."C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100