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APPLICATION FOR SANITATION PERMIT Permit No. _--- - 'Y' (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 No. 549. JOS ADDRESS AND LOCATION - ---------------------"T' A ��c ------------------------------�;----------- Owner's Name------------- -- ------ Phone----4j_3___"_�-�-- ---- -- -------•- Address----------------------------•------------------------------------•-------------------------- -------------------------------,----------------------------------------------------------------------------__ Contractor's Name-•-----------------------•--------- &� \........ ---------------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: ---I---- Number of bedrooms 1-`14umber of,baths _1____ Lot size ---- _- ^- -_____________________ Water Supply: Public systerrl ommunity system ❑ Private ❑ Depth to Water Table ______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B_44erdpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yeses-Pds ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---gQ� R-Distance from fo ncl Pion-7:4_�' __.Mate r'al_______1_ _______ ______ _____ No. of compartments------ ,,",I�~-"-1�------Size- -s�--x-- •---Liquid depth----------- ----_---Capacity____ ---�---- -- Disposal Field: Distance from neares wellli�Q_t]t.O, Distance from foundation__ Distance to nearest lot line__ I-i 4 Number of lines_____________ __________Length of each line_ - _ _� "__ _ __>�Nidth of trench____ ___._ ______-_______: Type of filter material __ ._1, Depth of filter material__-�_ Seepage Pit: Distance to nearest well----------------------Distance from.foundafion---------------____.Distance to nearest lot line__-___________ ❑ Number of pits---- ------ Lining material--------=---'---_-----Size: Diameter-----------------------Depth-------------------------------- Cesspool: Distance from nearest well----------------Distance_from,.foundation--------------------Lining material------------------------------------- 11 ___________-________-_--- _____❑ _ __.5ize:..Diameter--------- - - ='Depth-----------------(----------------------------------Liquid Capacity---------------------- ----gals. Privy: Distance from nearest well-------------__.--------------------------- Distance from nearest building------------------------------------------ Distance _________-__-- -____-________-__-------_.Distance to nearest lot line---------------------------------------------------------------•----------------------------------------------------------------------------t Remodelingand/or repairing (describe) ----------------------------------------------------•-----•-------------------1-----------•--------•----------- -•------------•'••- - - -------------------------------------------------------------------------------------------------------------------•--•---------------------------- 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 runes and regulations of the San Joaquin Local Health District. --------------- --- --------------------------------------(Owner and/or Contractor) By: ----------------- - -'--------- =---------- ------------------------------_------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing sizeof lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY --------------------- DATE----- `+ fAPPLlCATEON ACCEPTED BY *" REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------ ---•------- BUILDING PERMIT ISSUED---------- ------- +------ --------- DATE---------------=------------ ,------------- - ----=-- ----- ---- ------- _ + � ! zt.r Alterations and/or recommendations:__- ._____._ *__- ... , Ar ------------- ------------------------ - bF' [3' - - v , ---------'— ------- F---------f-----------------•---•`---------- --r--------------- ---------- t ------------•------------------------------------•---• --------------••- •- F- ------------------------------------------------------------------ ------------------ - ------- --------------------- --- - ___- /J FINAL INSPECTION BY------ ------ -----/•------------------------ ------ 4/ ----. Date._-. __ J O SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street y .• Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M Revised W-2100