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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 d s ed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------211-`l- --� �`* +~ J Owner's Name--------------------------------------- ------ _ Phone � n Address.-----p(-p ' -- ---- - ••- ---- I°�`1 ---------------••-----•---------------------•---- Contractor's Name--------------------------------- ---- --- --------------- Phone----'T�^f_&&7------... Installation will serve: Residence §( Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._--- Number of bedrooms _--- Number of baths ---i--- Lot size __-nL(%-^-�-f Z-_-------------------- 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 ❑ Aclobeo Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes ❑ No ❑ r ` TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 5 >tic Ta :r Distance from nearest well-----------------Distance from foundation--------------------Material----------------._..--------_---__________------- I No. of compartments------------- - ----------Size-----•--------------------------Liquid depth--------------------------Capacity--------------------- Disposal Field: Distance from nearest weilk-C ......Distance from foundatt' n-1S__'_ _-.Distance to nearest lot line__4---------- Number of lines---I-------._i Length of each line--_(Q N �' ---- Width of trench-- o� ----------- Type of filter material-_-_ -`IPL __ Depth of filter material-----f--p-_--- g - .r -------Total length -C-!!------------------------ Type 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----.---------.---___-_-_____...----... ❑ Distance to nearest lot line.----- --------------------------------------- -----------------------------------------------------------------------•---------------------- Remodelingand/or repairing (describe):-------------------------------------- ---------------------------------------•-------•-----------------------••--•------------------------------------- -----------------------•--•---------------------------------------------------------------------------------------------------.----------------------------------------------------------------------------------------------- -------------I------------------------------------------------ ------------------------------------------------------------------------------------<------------------------ ----------------------------------•----•--------------•-----------------------------------------------------------------------•------------------------------ --------------I---------------------------------- ----------------------------------•-------------------------------------------------------------•-----------------------------------------------------------------------•--------------------------------------------------------- I hereby: a ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sate laws, an rule nd re lations of the San Joaquin Local HAalth District. (Signed} 'L ---- -- --- mor Contractor) ---------(Title)--- +�n'►�i-1 � (Plot plan, showing size of lot, location of system in r ion to wells, buildin , etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------------------------- ---------------•-------------------- DATE----------- REVIEWEDBY--------------------------------------------------- ------------------------------------------------------------------------- DATE---- ------ / -------_---------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------- ---•----------- Alterationsand/or recommendations:--- ------------------------------------------------------------------------------ ------------------------------------------•---------------------------- --------------•-------------------------------------------•-------------------------------------------------------------------------------------•------------------- ------------------------------------------------ ----------------------------------------------•------------------------------------------I---------------------------------------------------•----•-•----------------•------------------------------------•------------------- ------------------------------ ---------- ------------------------------------•---------- - ----------------------------------------------------------------------------------------------------------------•-------•-------- FINAL INSPECTION BY:.-------- Date -yet - L=j ------------------------------------ SAN JOA QUIN 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 10-52 Revised W-2100