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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) -1 i Date Issued _____________________ 0Q 1—( 9 Applical-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri elf d, This application is made in compliance with County Ordinance No. 549. S 7 (AIAJOB ADDRESS AND LO2_6 ' a 1 ? IATIO Owner's Name----- [ r 6&,4nL_0,---------- - ------------------------------------------ Phone--------------------•--------------- Address4 ?-----------------------------------•-•-----------------------------------------------------•------------------•---•---------------- Contractor's Name--------------------------------- -------------------------------------------------------•-------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial E] Trailer (3el E]iiler Court MotOther E]Number of living units: -------- Number of bedrooms __2—Number of baths --- Lot size ------:7;.x--�-7---___________-- Water Supply: Public system ❑ Community system ❑ PrivateX Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loarr�,)g,, Clay Loam ❑ Clay ❑ Adobe EW'Hardpan 0 Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) P ® Sep is Tank: Distance from nearest well-,5v------Distance from foundation------/ .-------Material---------------------------------- ------------. No. of compartments..---- -------Size----------------------------,---Liquid de th__---_._____..._________._Capacity el Dis asal Field: Distance -From nearest well_. ._..._Distance from foundation____/P___ Distance to nearest lot line.--_.,�___ Number of lines----- '�__. ________-_Length of each line-________-.-�_C-�__.___....Width of trench=__ . Type of filter materiai_ ...._Depth of filter material---------1?t'I-__-.Total length--------------------- Seepage _____{_____________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 __,r----------------- ---------------- -- ❑ 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)------------------------------------------------------------------•-------------------•---------- ---------------------------•-------------- ............ AI ��. i -----------------------------------------------------------------------•------------------------------------------------------------------..-•-------------------•--------•-------...-------•------------•------------------- 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�rpules and regulations of the San Joaquin Local Health District. (Signed)...... f `"-- ---- = =-\ /--------------- --------------------------------------------------------------:--------(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---- ----------- ------- -----------------+--------------- DATE----------:2.. � _. REVIEWEDBY--------------------------------------- -- - -- -------- ------------------- ------------------------------------ ---- DATE---------------- _-------- BUILDING PERMIT ISSUED-------------- ------------------- ------------------------•------- ---------------------------------- DATE.------------------------- -------------------- Alterationsand/or recommendations:---------------------------------------- ----- -------------------------------------------------------------------------.---------------------------- ------- ------------------------------------------------------------------------------------- ------------------ --------------------------------------------------------•.------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ----•-••-•-•------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------- ----------- ------------------------------------------------------------------------•---------------------------------------------•--- ----------•----------------------------•------------------------------------ -•-------- --------------------------------------------------•--------------- FINAL INSPECTION BY: •' -------• - ----•--------------- Date------ ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Was+ Oak Street 132 Sycamore Street 814 North "C" Street - Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOO 12-sa