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APPLICATION FOR SANITATION PERMIT Permit No. __Zp(�' L_-o..._ (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----------I_ --------------3afra Owner's Name-------------- Phone------------------------------------ Address Y_ _�r- _ _r _ Address-------------------------------------------•---- �1 •-.1 Contractor's Name--•--------------•-------- ----•-----------•------------------------------------------------------- ------------------ Phone------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other^^❑ __1----Number of living units: __ ___- Number of bedrooms __ Number of baths ---I--- Lot size --------. o----�_/ C�_----------------- Water Supply: Public system Vcommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam E] Clay El Adobe Hardpan ❑ Previous Application Made: Yes E] No VNew Construction: Yes V No ❑ X TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well------—_--_Distance from foundation--_-- -_f------ No. of compartments__________+�_______Size_______ _ X_ -Liquid depth------------ {-------Capacity._ __ _ .+ { Dispos Field: Distance from nearest well------ Distance from foundation___._R3__ __D Distance to nearest lot lin --__._S�_... Number of lines----------- ___ Length of each line--- _`__.Width of trench_-________r�-_____________________ Type of filter material__!� tpG ___Qepth of filter materiel-------_/_ _ -----Total length---------___ r___________--. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- r_1 Number of pits----------------------Lining material------------------------Size: Diameter_.--------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- 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)----------------------------•----------------------------------.--------------------------------------------------------------------------------....... -----•-----------------------------------------------------------------• ..........---------------------------------------•---------------------------------------------------=------------------------------....--------".. --- -------------------------•------------------------ ---------------------------------------------------------------------------...------------------------------•------------•------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an egulations of the San Joaquin Local Health District. { g � ---------------------------------------- - -- ------------------------------------------- --------(Owner and/or Contractor) ... By:---- ---------------------------------- ---------------------------------------------------------------------------------------(Title)--------------- -------------------- ------------------------- (Piot plan, showing size of lot, loe tion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY e Alli APPLICATION ACCEPTED BY----------------- -- - -- .--- --------------------- ----------------------------------------- DATE--------- REVIEWEDBY--------------------------------------------- -- - ---------------------------------------------. DATE------------------------------ BUILDING PERMIT ISSUED----------------------------------------•------------------------------------------------------------- DATE Alterations and/or recommendations------------------=-------•------------------------ --•--------------------------------------------------- -------------•---------- ------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------•------------------------------•------------•.----- - ----------------------------------------------------------------------------------------------------------- ---------- ice' FINAL INSPECTION BY: ----�1-r �'----- ----"44- -------------------- Datl� - -/----------------------•----------------------------- 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