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APPLICATION FOR SANITATION PERMIT Permit No- -- -------- -- (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application-is made in compliance with County Ordinance No. 549. I •� JOB ADDRESS AND LOCATION--------_ Owner's Name...-- 1, — --`•- -- n -'�rr'-----------------------------------------------------------. - Phone------------------------------------ Address----------- -•--------Address----------- --.._.. ./.�r- . - ------------------------------------------------------------------------------------------------------------------- ------------------- Contractor's Name------- ------------------------------------------------------------------------ ------ Phone-------------- Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I-___ Number of bedrooms Number ofbaths _/____ Lot size _-_41-9-XN _____________ --------- Water Supply: Public system ❑ Community system ❑ Private 2-1 epth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe &--Flardpan ❑ Q !� Previous Application Made: Yes ❑ No �ew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 'Septic Tank: Distance from nearest well__ r __--__Distancejrom jundaation __________.Material__J_�IF�,�_ No. of compartments------J,I-------------Size--- - -- - - ---Liquid depth--------- ----------Capacity-_- � �1 r Disposal Field: Distance from nearest welL_.�_Q_____Distance from foundation_�Q_!_�__Distance to nearest-lot line--/,e---- } ` � hyumber of lines-------/ --------------- - ----------Lepgth of each line------- -__'-_______.Width of trenc ______ �--------------- Tpe of filter material___1/� �C__:___Deth of filter material____ Total length_ d__----c________________ Seepageline +9 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______-____________________--______- i ❑ Size: Diameter-------------------------------------Depth---------------------------- -------------Liquid Capacity----------------------------gals. ' r• Privy: Distance from nearest well___---------------------------------------------Distance from nearest building__________-____________________-_________- '. ❑ Distance to nearest lot line------------------------------------------------------------ •f Remodeling and/or repairing.(describe):------------------------------------------------------------- ------------------------------------------------------------------------------------- a -----------------------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------ i -------------------•------------------------------------------ ------------------------------------------------------•----------------------------------------------------------------------- ---------------------------------------=----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin County ordinances, regulations of the Sart Joaquin Local Health District. Si ned . _ S.,�-'t-2to----� -----tate �aws;,an ru es an( 9 } • ::.-----------.•--------------------------------------------------------------------(Owner and/or Contractor] By:-----------------------------------------------------------------=------w ---•---------------- ---(Title)---------------------------- ------------------------------------ (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---i------- ----------------- - = ----------------- - --------------------------------------- DATE-------- ' REVIEWEDBY------------------------------------------------------------------------------ ---------------------------------------------- DATE---------;-------------------------------•---------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------' Alterations and/or recommendations:__________._ f ---------•- -------------- ------------------------ 1------- -r--- --------------- - ---------- -- - ______________ _____ _ _ _------------ ___________________________________________________________ --------------------/----------------------------------------------------------- ------------ -------------------------------------------------- ______ _ 4 ________________________________________________________ 4-1-1--A __ ----------- a k ' A '---------4 - - ---------------------------------- Date------ FINAL INSPECTION BY:_-•------------- --- - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 'i,` , G • 130 South American Street 300 West Oak Street 132 Sycamore Street 814-NorA-�"C" Street Stockton, California Lodi, California Manteca, California Tracy, California Vis• i � �. F*y. ES-4-2M 8-51 Revised W-2100 i