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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. This application is tali! co r ante with County Ordinance No. 549. __. JOB ADDRESS AND OCAJTION--- ----- - ----- - - - -- -- , . _ - ----- _Y Owner's Name �J --------- Phone Address-------F �� Q -------------- -- Contractor's Name---- ----------------•----- ---- -- / -----• -- -----------------•------------ _. Phone, �`��Q Installation will serve: :Residence ❑ Apartment House, ❑ Commercial ❑ Trailer ourt ❑ Motel ❑ Other Number of living units: -= Number of bedrooms Number of baths p-`----- Lot' •�-.-- Water'Supply: Public system ❑ Community-system ❑ Private ' Depth to Water Table Z_7 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand' y Loam E] Clay Loam E] Clay ❑ Adobe Hardpan ❑ _- Previous Application Made: Yes [❑ No V NeW(Construcfion:_ f] CAYes No r T+ TYPE OF INSTALLATION AND SPECIFITIONS: } (No septic tank or cesspool permitted if public sewer is available within 200 feet.) = _ Septic Tank: Distance from nearest•well,/Q----- Distance from fo ndation___ d________ No. of compartments____cP,------ _-------Size__ _� _ -------Liquid depth____ rl__-__._Capacity ____ -_est.(/ ;Dis,osail Field: Distance from nearest weil_At--------Distance from foundation__z;Z_4_ -------Distance to nearest lot line______,__ Number of lines________ ____ ____ ' _ Length of each line_-_-_.o'_0 -._`:____.Width of french___ - ------------------ Type of filterimateriai---- (.- Depth of filter material---- ------Total length___. _Q___________________._________ Seepage Pit: Distance to nearest well_ ----------------__---DiStance from foundation______ ___________.Distance to nearest lot line------------------ 4❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------- from foundation-----_--------------Lining,material------------------- ------------ 1 ❑ - Size: Diameter-------- -------------------- -----=Depfh--------------------------------- --------------- --Liquid Capacity----_----------------------gals. Privy: Distance from nearest well________________-- ------------------------------_ Distance from nearest building---___..__.______-_____________________-_ ❑ "" Distance to nearesf'lot Fine:____ t-^ ----------------------------- Remodeling and/or repairing (describe):_.___ _flrX�tt --.• / -------------- - 1 --------------------------------------------------- ---•----- --------- �/ �+ / ---------- --- =------------------------- -------------------------------------------------••-------------------------•---------------------------------------------------------------------- ------------------------------------ -------------- -•---------------------------•---------------------------•--------------------------•-------------------------------------- -------------------------------- I hereby certify-that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regula+ions of the.San Joaquin Local Health District. ; , (Signed)----- ---------- '=--------- `�""- ,- % (Owner and/or Contractorl ' By: E = ...(Title)---•-amu?- -•------•----------------------------------- (Plot plan, showing size of lot, location of system relation to wells, buildings, etc., can be placed on reverse side). + FOR DEPARTMENT USE ONLY APPLIt CATION ACCEPTED BY -------------- DATE.---------- REVIEWED BY__. = -------------- DATE------f - -..-------•-----------•---•---------------- BUILDING PERMIT ISSUED------------- = ------•---------------------- ------ DAT --------------------------------------------------------- Alterations and/or recommendations:__..__. _ s ---•---------------•-----------•----------------------------------- - - ------------------------------- ------------- t _ •--------------------------------------------•-------- BY:;-A4 FINAL INSPECTION --- ------------------ ---=------ Dae----------�. _.. ._ 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 I ES-4-2M ; Rev,sed W-2100