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APPLICATION FOR SANITATION PERMIT Permit No. r`� [�f� , (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 made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-----------ADO Ft---, ------------------------------------------------------------------------- Owner's Name------------------6 0-&j-----------E/k-2 tJ e-'--'p--------------- --- -- - - -- ----------------------- --- - --- ----- Phone Address------------------------------- -�--6-2- ------ --- �--------------------------------------------------- -----------------------S------�-----�--- -- Contractor's Name------------------------------------- a --------------------------------------------- --------------------------------- ------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/--- Number of bedrooms __. _ Number of baths /____ Lot size -------#a-X---CCS_-J------------------- Water _-_______________Water Supply: Public system X 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 L�( Hardpan ❑ Previous Application Made: YesX No ❑ New Construction: YesA No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well___ ________Distance from foundation_-_-142-------Material---��_----_---___ ________________-_________- ------ _ X Liquid depth-- .. p y------- No. of compartments------------- _ Size_____ _____,----Capacity �.D___ Dis os-I Field: Distance from nearest well.-----r-_--Distance from founc`ation-----/<;�.......Distance to nearest lot line___-_--_ Number of lines______________y ��-----------Width of #Tench-----------�-� -------------Length of each line______-_--- �� --y _-p ------------ Type of filter material ________________Depth of filter material- �� _____ _________-_Total length_________l_Z0_/_Z0__747............. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- d ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- W 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--___-______________________________-___. ' ❑ Distance to nearest lot line------------------- -------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------- ------------------------------------------------------------ --------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------- ---------•---------------- . I hereby certify +hat I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, St a laws, and rules and regulations of the San Joaquin Local Health District. �f � 1 (Signed)---- =�'�" " ------ ------- ------------------------------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------ ----------------------------------------(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------ l DATE }. ---------- REVIEWEDBY-------------------------------- ------------ -------f------------------------ --------------------------------- DATE------------------------------------ -- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- ferations and/or recomm dations---------------t- -- �?-- ------- ---------------------------------- ------------------------------------------------- ------------------------------------------------------------------------- ---- ---------------- FINAL INSPECTION BY:--------- ----------------- Date--� zl--41zz-------------------------------------------- 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