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APPLICATION FOR SANITATION PERMIT Permit Y {Complete in Duplicate} / ' - _ a date Issued l_I _ pion is hereby made to This 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 Ordinanc No. 549. _ , 4� JOB ADDRESS AND LOCATI N-------...� r�. - ------ -- _-�$ Y ► % f, i; --•- ------- T -------------------------- Owner's Name---•------ /. Phone. Address----------------•-------=---------------•-----------•---- - ------ - -----•--•--------------------------••-•-•--- Contractor's Name------ ----------------------- -- ------------- --- Phone. Installation will serve: Residence �( Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ Number of living units:,.J --Number of bedrooms _umber of bats __ ___-_ Lot size _______ 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 ❑ Cla cam ❑ Clay ❑ Adobe Hardpan ❑ �i Previous Application Made: Yes ❑ Noew Construction: Yes . o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: T s (No septic tank,or cesspool permitted if public se er is available within 200 feet.) Se tic Tank Distance from nearest well__ . istance from f" -da#ifln f k:_R``.Material____0h ii Noi of compartments------- ----Size---L`J - ---Liquid d th Capa( ----------- Disposal =a Field: Distance from nearest well_._- _ _. istan.ce from foundation___ _Distance to nearest lot line--,,;;). Number of lines____________ Length of each line------1_-_1L__- _------Width of french___------ _ .� Type of filter material __ - Depth of filter material -------------Total lengthI.. . Seepage Pit: Distance to nearest well-._________________Distance,f�om foundation--------------------Distance to nearest lot line_______.._.______ 1 • ❑ Number of�pits______________________Lining material---- f-------------------Size: Diameter-------{_-___. Depth ---------------------- Cesspool: Distance-from 9nea-resf�well------------------Distancelfrom foundation, __-------r------Lining material_________________`:_______ _- ❑. Size: Diameter------------------- _.•` = Depth. ' - Liquid Capacity--------------------- ' gals. Privy:; Distance from nearest st well---. ------_- - ,--- ___-- x . --------------------____-'_Distance from nearest building- s an-ce•- o'r�eares ot --------------- - - --------------------------- Remodeling and/or repairing (deTscribe)._--'-- --- ---------- '----------------f •-•-.......... r, ------------ -----•- _------ --------_--- -- ---- wry/ � ! -- -------- Ihereby certify that I have prepared this application and t t the worktealth be done in accordance with San Joaquin County ordinances. State aws, and rules and regulations`of the San quin Local District. ti (Signed)-_.-- {. .... ------------ (Owner and/or Contractor) 1 By:..... - -< t=--=--------------------------- -- ----- �----••------------_--------(Title)- = (Plot plan, showing size of lot, location of2system in relation to wells, buildings, etc., can be placed.on.ieverse side). FOR DEPARTMENT,USE ONLY APPLICATION ACCEPTED BY------------------�_.------_ t i--------------------------------------- DATE REVIEWEd BY " -- - ` 1------------------- --- DATE------------- ----- BUILDING PERMIT ISSUED------------•----------------- =----- t DA E------------` F Alterations and/or recommendations:_______ �'_-�`___ ` ---"------ ---------------- - ---------- .� > ------- � r, T/ r ----•--------••----=-----•----•---------- ------------------------- ' FINAL INSPECTION .BY:.------ --- ---- - - - - -------- Date------------- ,� _ ►a '. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 4-2M Revised W-2100 ''