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APPLICATION FOR SANITATION PERMIT Permit No. �� `� " s '1 `^ (Complete in Duplicate) Date Issued -- _i__ 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 ev- .... JOB ADDRESS AND LOCATION_ __________V____ I . ---------------------------------------------------- Owner's Name------------------- --- Phone--------------------- --------------- Address-----------------------------------4v _-L r-. A ------ ------------------------- -ContContractor's ractor's Name - ' -------------- --- ------------ ------ .G' ,—°-" - Phone—Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: )---- Number of bedrooms _/__ Number of baths _/-_- Lot size --- Wafer -Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _---__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes io ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is avaiJ6ble within 200 feet.) Septic Tank Distance from nearest wel __d Distace from foundation---/.c_-_------.Matar'al _--- _ No. of compartments S _ � ,f"" .r p - +4e� J�F Liquid depth - -------Capacity----IF --�--- Disposal F' r Distance from near st well- 4// Distance from foundation ��3 --------------Distance to nearest lot line__;-- - Number of lines__+ Length of each line---- t� > -Width of trench------- -- --------- ---------- 11 Type of filter ma terial.S_ - _ '-_-__�---Depth of filter material-- - ----------Total length_-_--- _ '__ _----_________-_--_ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line-------- - ❑ Number of pits----------------------Lining material----------------------- Diameter-----------------------Depth-----------------------•-----__--------_ _ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------------- 0 Size: Diameter--------•-----------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals' Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line-------- ------•-------•- Remodeling and/or repairing (describe): -----A -1--------_------------•---------------------- •+ .. --------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, ain4 rules and regulations of the San J quin Local Health Di riot. . -7. (Signed) ... - „( 00 : ,- ----- -----( and/or Contractor) By:--------- +•------- - --------- ------ -------------------------------------------------------------(Title)------ �-----(Own (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------- -------------------------------------------------------------- DATE---y—Y------ ------------------------------------------- EVIEWED BY -- --- DAT( - -------- ---------------- ---- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------- -------------------- DATE-------- Alterations and/or recommendations:------------------------------ ------ - ------------------------------------------------------- --------------------------------------------------------------------------------- --------------------------------------------------------------- ---------- ----------------------------------------------------------------- - - - ----------------- -------------------------------- - -------------------------------------------------------- � -11>1 f FINAL INSPECTION BY:-------- Y------ ✓ -------- Date- .. 1 . 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 8-51 Revised W-2100