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APPLICATION FOR SANITATION PERMIT Permit No.e; 4-a__------- .(Complete ___._.(Complete in Duplicate) Date issued _ /- sJ 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 Ordiin�jpce No. 549.. JOB ADDRESS AND ATION-- -- -/--.- �" ' --------------- Owner's Name----------- --- --- -------------- --- ---- ---' ----------------------------------------------------------- Phone-- ---------- Address---------------a -(------- - ---- -------•------------------------------------------- ----- ---------- Contractor's Name. '--- '.['� - lr--------------------------------- Phonej/ -.----- Installation will serve: Residence VO'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other ❑ Lot size_ _ �/ Number of living units: _L Number of bedrooms Z__ Number of baths � ,l�� _- ___ �!- 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 Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 'Septic Tan��: /,.� Distance from nearest well_________________Distance from foundation-------------------Material_________--_________________________________.� I ,P/' ❑' No. 'of compartments--------------------------Size--------------------------------Liquid dept------------------------ Capac�tY Disposal Field: Distance from nearest ell_____Ptl-____Distance from founds io /P_Jr to nearest lot line, �___•_ Number of lines_________+ Length of each line__ _�'��i __--.W;dth of trenc _____ Type of filter material�-_�!_� Cz,--Depth of filter material______________________Total length_.-______________________._ ____ ----------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------------ --- El _ ❑ Number of pits____________________Lining material-----------------------Size: Diameter-------------------- -Depth------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material________________________-_-_____ ❑ Size: Diameter----•----- ------------------------Depth---------------------------•--------------- --------Liquid Capacity----------------------------gals. ------------ Distance _____-_ -_Distance frorrie ------------------------------ Privy:,_ '�:�. �� •Distance from;nearest•well__-_:- ___-'_ _- -�, ❑ Distance to nearest lot line ------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe): "---�'-Vl---------E"--------•-•----------- = -------------------------------- I -------------------------------•----------------------------------..--------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------.---------------- 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/andrule and re ulations of the San Joaquin ocal Health District. f(Signed)--------f1#- __/t — (Owner and/or Contractor) BY: � ----- ----------------------------------- (Title)---) '�- --------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reve side). k FOR DEPARTMENT USE ONLY APPLICATION ACCEA T ED BY ------- ------------------------------ --'------------------------- ------ DATE---fes` REVIEWEDBY--------------------------------- -- ------------------------- ------------------------------------------------- DATE- -----_/_ - BUILDING PERMIT ISSUED---------------.-- ----------------------------- ------------------------------------------- --------------------------------------- DATE------------- - --- , Alterations and/or recommendations:--`--------------------- ---------------------- -------------------- ------------------------------ t -------------------------- ------------------------------- ------------------------------------------------------------ -----------------------I --------------------------__. ---------------------- �I FINAL INSPECTION BY: .__15_1_ _' _ Date J °fir ---�- -�/�f-/'-r�----1------- -----------�--- -- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 4 '