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APPLICATION FOR SANITATION PERMIT Permit No. _ - —'1- (Complete in Duplicate) Date Issued �— Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thework herein described. This application is made in compliance with County Ordinance No. 549. � --------------=----------------- JOB ADDRESS AND LOCATION--------- r�__--r---�`-�--��---------- --------��-�-�'----------- =- - -----•---- '� --- --- '� Owner's Name-------- ---------- ,JP hT_ _t .r -------- -�----------------------------------------------Phone---------------- ------ > �� G�Gt1 � Address --------------------------------------------------------------------------------- Contractor`s Name--------------- ------------------------ ------------------------------I ---- ---------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unitAy_*4mber of bedrooms _Y Number of baths _-2 Lot size -------- -X -'1-------•- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- .ft, ti Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay..❑. Adobe,K Hardpan ❑ Previous Application Made: Yes No ❑ New Construction: Yes ❑ No 5C 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_______-~Y__Distance from faunel ation___-l�________.Maierial_____ of compartments----- - ----------Size--- _ _ ----Liquid depth----------Capacity---------- No- ! d Field: Distance from nearest well_-_--`-_ _____Distance from foundation____L� -----.Distance to nearest lo ----------------- Disposal Number of lines------ --i'y'r'''-'-?�--Length of each line---------"'�"--;......... -----.Width of french----------------------------------- - of filter material__L-�_--------------Depth of filter material______fe_ _ ____Total length_______________-S�_��_`� � 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------------------------.----------------. V' ❑ Distance to nearest lot line-- ------------ -------------------------------------------------------------------------------------------- Remodeling and/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 ordinances, State I s, apd rules and regulations of the San Joaquin Local Health District. — -------- ----------------------------------------------------------------(Owner and/or Contractor) (Signed)-- -------------- 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------ F —----------------- REVIEWEDBY----------------------------------------- - - -------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------- ' � DATE-------------i---------- -------------------------- ` ` ------------- --------- """ "" ""r --- Alterations and/or recommendations: `- ------� ------------- ------------------------------------------------------------------------------------------------- ---------------------------------------------- ------.------- ----- ------------------------------------------------ -------------------------------------------------------- __ 4- FINAL INSPECTION BY:� _ "` '`----------- 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 E5-9-2M 8-51 Revised W-2100 r