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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) pp s-- Date Issued 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. 5°I r JOB ADDRESS AND LOCATION--- ------- f#�^ /- ----------------------------------------------- Owner's Name--�.�-£/•-------L" �R'!-(�?,i L: �P—---------------------------------------- --------------------------------- Phone-- 1?0' ------- Address--------- ------ Address--------- Contractor's Name �U4l ------ ---------------------------- Phone----------------------------------- Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _A___ Number of bedrooms _-.__ Number of baths .- I___ Lot size -------------------- ---- Water Supply: Public system.K Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob64 Hardpan q�kN Previous Application Made: Yes ❑ No K New Construction: Yes Z No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: y (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----- f_____Distance from foundation-----1.0-----------Material------ . 'F"G! -- ____________ •& No. of compartments------ -------------Size-- -- --- __--Liquid depth--------Y---------------Capacity_---? -¢----- Disposal Field: Distance from nearest well----------_Distance from foundation----RQ_*______Distance to nearest lot line_______If--- 4 Number of lines______________�f i________i--_____Length of each line________ 11 1" �----------Width of trench- - -------------------- Type of filter material____ fac_�__C144�epth of filter material____�> -__--___-___Total length_________ __"_____________________ Seepage Pit: Distance to nearest well_________-_ Distance from foundation-------------------Distance to nearest lot line_________---_____ ❑ Number of pits----------------------Lining material---------------_-------Size: Diameter.----------------------Depth--------------------------------- 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------------------------ ______________- ❑ Distance to nearest lot line--------------------------------------------- - --•-------------------------------------------------------------------------------------- ---- Remodelingand/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Si ned__ � 9 of the San Joaquin Local Health District. , ordinances, State laws, and ruled regulations ---------------------.____-______________________________________------ -- --- ( g } ------- - -(Owner and/or Contractor) B (Tale)_ --------------------------------------------------------------- (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------------ [ ----------------- --- ----- - ------------------------------- DATE------------ { - 1�I - -- -- -- ---------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE--------------------------------------------------- j BUILDINGPERMIT ISSUED----------------------•------------------------------------------------------------------------------- DATE------------------------------------------------------ Alterations and/or recommendations------------------------------------------------------------------------------------------------—--------------------------•--•------------------------------- --------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----- tl----------------------------------- Date-----------3--,---/----- a'f-------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 5-51 Revised W-2100