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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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND Owner's Name '�.� qq 4 /� ------•--- ----------------------------------------------------------------------------------------------- ------------- -------------------------- /1.--.- -- -------------------------------- ----------------------------------------------------- Phone Address----------- -D.ti--------l.V'--•--��..'--- ------ --------------- --------------------------------- Contractor's Name__________________ ------------------------------------------ _.-_ i't4,� - --------------------------------- ----------------- --------- -------------_____ -------- Phone I part ----�"_^."��,--------- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms _y- Number of baths J---- Lot size ."..__-_. Water Supply: Public system . _...._"...._--._ Y ,< 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% Hardpan ❑ Previous Application Made: Yes ❑ No& New Construction: Yes K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weii---_" '----Distance from foundation..._ 0�_-_____.Materia._-../ 4P 14 No. of compartments._-._ -v'L ___ $ Size.. X -- Liquid depth -�Y- / Disposal Field: Distance from nearest we i_________________Distance from foundation-..__ .. / I----____-_.Distance to nearest lot line.____LS' ._-___ Number of lines--------- --------------_ Length of each line_L ,'?,, P--_--..Width of trench .---------------------- Depth Type of filter material_/A*_�rVC_E_ of filter material..._.___/Qr__' 1 ------.Total length.--------- -Seepage -Q- Pit: Distance to nearest well 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---------------------------------------------r---Distance from nearest building ❑ Distance to nearest lot line - Remodeling -------------------------------------------------------------- and/or repairing (describe):__._ ---------------------------------------------------------------------------------I-----------------------------------------------------------------------------------------1-1-------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, d rules egulations of the San Joaquin Local Health District. (signed]... __ ----- ------- - --------------- ---------------------------------- ------------------------------------------- ---------------------------------(Owner and/or Genkacja . -------------------------------------------- Title (Plot plan, owing 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.._---_._ / REVIEWED BY �/ DATE--------- - ------------------------------------------------ ----------------------------------------- - --------- DATE---------------- ----------- yr---------- BUILDING PERMIT ISSUED---••---- ---- - ------ ------ --�-------- --------------------- ---- ----------------------------- - --- ------- DATE---------------•----------- Alterations and/or recommendations---------------------- " -------------- FINAL INSPECTION BY:-------------------------- ) �y -------------------------------------- --------- ------------ 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 Mantua, California Tracy, California E5-9-2M 8.51 Revised W-2100