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�r APPLICATION FOR SANITATION PERMIT Permit No. � d (Complete in Duplicate) V` Date Issued Applical-ion is hereby madeifo the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance ith County OrdinanceN. 549. JOB ADDRESS AND LOCATION..___ -. _-- _.------ )� -------------- ------------------------------------------•--------------------------------------------------- Owner's Name------- -e__ --'-•--I[hliLr� i.- --------------------------------------------------------- Address------ .1 I ---.- Phone.- --------•---------••- ........?--••----- ----------------------------------- - Contractor's Name_--. --------- ,. '1------------------------------------------------------------------------------------------------------------------ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Tra'ler_/- Court ❑ Motel [I Other E]i / Number of living units: ___ Number of bedrooms �_ Number of baths ---- Lot Lot size --- Water Supply: Public system [l�Community system ❑ Private ❑ Depth to Water Table -------- ft. 1 Character of soil to a depthIof 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay E] Adobe�Hardpan E]Previous Application Made: Yes E] No New Construction: Yes ,-No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w{ (No septic tank or cesspool permitted if pyblic sewer is available within 200 fee#.� I /ij � �3 Septic T�arak: Distance from nearest well- ._. Distance from foundation_____ _ _______.Mater I__________-______._.___._.- _ j No. of compartments__-..... ^----- --- Size---- [' _ Liquid depth----------- -------------Capacity--��.------------- I — Disposal 'eld: Distance�from nearest weil_.� Distance from foundation/,a'..._-..__.Distance to nearest lot li a _____..__. Number poi• lines___.__ __ -.______. T -- Length of each line______ Width of trench-__---% T e or filter material__-_ (! —_ r� _/--------------- Type YP r Depth of filter material___-- _- -------Total length-__-.-- --a2 l�_______________•---- { Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line._____________.._ ElNumber of pits----------------------Lining material-----------------------Size: Diameter----.------------------Dept h......-------------------- Cesspool: Distance 11'from nearest well--------_--------Distance from foundation.___--------------- Lining material___ ❑ Size: Diameter------------- ---- -------------------Depth----------------------------------------------------Liquid Capacity_----- --------------- gals. N - Privy Distancel1from nearest well-------_-----_-----------------------------------Distance from nearest buifding-------------------------------------------- ❑ Distance!to nearest lot line.._____:-._____.._._ Remodeling and/or repairing (describe)--------_---------_----------_------------------_--------------------------------------- ----••----- - ii ----------------•----------- -------`-----•------•-------------------•----------------------•----------• -------------•--------••------- II ------ _ -------- ---•---------- ----- ------------ ----------------------------------------•---------------------•-------- -------------••----------•------------------ ---•------•--•---------------------------------- 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 and�regujlaffiorts of the San Jo -quip al Health District. Y (Signed) ------------------- ----------------- ------------------ --------(Owner and/or Contractor) syr-------------------------_---I�----------- ----- ----:-------------- ---------------------------------------------(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 APPLICATREVIEWED BY ACCEPTED BY -----:-------------------- ......... ----- ----------------------------------------------- DATE - --�M-- --- -------- DATE------ I ---------------------- ----- - -- -- - - BUILDING PERMIT ISSUED._(-------------- ' --- -- -------- ----------------------------- - -- DATE.. Alterations and/or recommendafions:---- --------- ---- -------------- ;�. -------------•------------------- ------------------------------- ----- ---------•---------------------------------------------------------------- I ----------------------------- -- ---•----------------------------------------- ----•-------------------- -------- --------- - - -----------•----------------------- I F ----•----•---------------------- -----------------------------------------------------------------------•---- t. FINAL INSPECTION BY:-.-r ----- Date------------------ -- - - 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 E5-4 145446 A7WOVD