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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) - Date Issued AppLica+ion is hereby r�do�heSanoaqun Local Health District for a permit to construct and install tthe This application is made in compliance with County Ordinance No. 549, work herein described. JOB ADDRESS AND LOC TION--.-__- -______-_. �/ - ---- - ` = 'Y`'` ---------- - Owner's Name ` �------- ---------•----------------- -•--- -------- --------------- Address... . ,. _ 4 Phone -----•--------------- --- --- -------------•---------•----•--------------.------ ---------------------------------- Contractor's Name------------------- '- --------=-------- ----------------------------------------•--- Installation will serve: " Residence partment House ❑ Commercial Phone---------------------- ❑ Trailer Court ❑ Mot ❑ Other ❑ Number of living units: __1_- Number of bedrooms _Ca Number of baths - / - Lot size --------4'4�'` Water Supply: Public system ,❑ Communitysystem Y ❑ Private ' Depth to Water Table-- 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 r 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 well -- from foundafiion---------- ---_.- Material-----------------------.--------- ------ No. of compartments . ---Size-------------------------------7 Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest welt....._-_-___-._.,.Distance from founda#ion---------------------Distance to nearest lot line----------.-____. ❑ Number of fines--------------------------------- -Length of each line.---------------------:-----.Width of trench---------------------- --- Type of filter material-------- ---------------Depth of filter material-------- - ------- --._Total length----------------------------•--------•-•-- Seepage Pit: Distance to nearest weli._�i(�---___-Distance fro founda ion----.�_ D stanc�ej to nearest lot line-__-- ___- Number of pits-------- ------------Lining material - _-_ ize: Diameter--.- __ - ��-'-7`----.Depth------�--- Q Cesspool: Distance from nearest well-----------------Distance from foundation---------.----------Lining material-_ 0 Size: Diameter----------------- --------- -----------Depth--------------------- ------- . _- ----------------------- - --------LiquidCapacity----------------------------gals. Privy: Distance frorri nearest well--- Distance from nearest buildin ❑ Distance to nearest lot line-------- ----------------------------------. g---------- ------- --------------•---- Remodeling and/or repairing (describe)------------- 'a --------------------- --• -----•--------- �. ------------------- , - , f ---- _ '� 4 t 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 r s and re ulations of the San Joaquin Local Health District. k -''—k I (Signed)-�--------W__ ----------------------------= - ---------- ----(OB .:.---- - _ caner a d/ C tr ctor) n or on a (Title) ---- ---- ------------------------------ - -- ---------------- P of plan, showing size of lot, location of system ' r t on to wells, buildings; etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------- - � REVIEWED BY - -------- --------------- ------ DATE--------------------------- -- ------ ----- ------------------ ---- -------------------- BUILDING PERMIT ISSUED---------------------------------- ---- -'�-------- Alterations and/or recommendations: - ----------------_----.----•- ----------------------------------- l -------------------' --------------------------------------------------- - .-------------------------------- ---------------------------- FINAL INSPECTION BY----- -------- - ---- r ---- Date-------`s7/.-- ----------- 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^�M 145446 ATWOCD 12.54