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APPLICATION FOR SANITATION PERMIT Permit No. ........................ (Complete in Duplicate) Date Issued 4_2NI Applica�ion is hereby made to th 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. Ae -------�11--------------- JOB ADDRESS AND LOCATION_ ____.____ ----------------i4ig --- -------------------- .. s 4� ------- ---------- r Owners Name------ --- Phone----•----- ------ - - - - ----•----•------------ --- 1 . 3-L;_� - --�- ---------------------- ----- ---•--------•------------------------------- Address_....------- �'---- -- " Contractor s ame-------------= -- ---- ---------------•---------------- --------- -------. Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial (] TrailerCourt ❑ Motel ❑ Other [INumber of living units: ---/--- Number of bedrooms __; /✓Number of baths -___L___ Lot size ____"__�--3I --� � 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 ❑ Adobe Hardpan ❑ Previous ApplicationnMade:-Yes ❑ No" New Construction: Yes lAl No ❑ f TYPE OF INSTALLATION AND SPECIFICATIONS: ( p P p ewer is available within 200 feet.) Septic Tank: Distance from nearest well__. "_ Distance from foundation-----1_!�_____-Mat�efia� ___ ________________------------- 00 ___�____ No septic tank or cesspool ermined if public s �, - -lQ_ - --_Liquid de th-------'�f`. '7' _.Ca No. of compartments_.._. -- / Distance from foundatio __ _ _ _p_____ Distance to nearest lo# lin ---------------- I f U Dispo I Field: Distance from nearest II_" °` J Number of lines----------- ._--------"---"---- ength of each line------ _: Q---=----Width of trench---------�_ -_-------------- Type-of filter material------ of filter material__-____._ /_ .j� Total length________ _____________________ (� 4 Seepage Pit: Distance to nearest well----------------------Distance from foundation_:________.-_______.Distance to nearest lot Gne----------------- Number of pits----------------------Lining material---=- ----- -----=----Size: Diameter------------- --------Depth--------------------------------- - 1 tDistance from nearest well-----------------Distance-from foundation-----_____----___. Lining material-_____-________.__-_-_________ ! ❑ 'Size: Diameter---------------------------------------Dept h------------------.I----------------------- = Liquid Capacity----__-� ---t f9s. ak.-. - - v Privy: Distance from nearest well-----------______________________________________Distance from neareO build'ng------------- ❑ Distance to nearest lot J line--------------- - -------------------------------------- - -------------- ------------ ------------- r -Y.A_-r:-� _ - - ` -�S / Remfo-dxeling- nd/or repairing (describe):. ):_ _-- t -•-- ---.----:------------------------- --------------- -------------------------------------------------------------------------- ---` c---- -------------------------------------------------------------------- --------------------------------------------"--------------------- r 1 hereby certify that 1 have prepared this applica+ion and that the work will be'done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Si nedLe --------- V� ---------------(Owner and/or Contractor) By:-------------------------- ----- - ----- - Ti+le ------------------------------------- ----------------- -- -- - ------------------------------------------- ------------- -------- - -- -------- (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 -- - --- --------- ------------------------------------------ DATE------------------------------------------------------------ REVIEWED ACCEPTED BY----------------- -- ------------------------------------------------------------------------- DATE REVIEWEDBY------ ------------- -------------------- --- -- -- k BUILDING PERMIT ISSUED---------------------------- --- DA-1 E and/or recommendations:------- ------------------------------------------------------------------ ---------- -------- { ------------------ FINAL INSPECTION ,BY----------- ----------- Date 1 - 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--21A Revised W-2100