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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued ��,Z,-v-3- c �r3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and insfa t e°wor°k erein described. Th's application is made,in complian with Coun y Ordinance No. 549. 6—e , JOB ADDRESS AND LOCATIO _ ---- --- - ----------- r { Owner's e s Name - ------- - ' ------------- o Address-- ----------- ----------- - ---n --------------------------- -- --_- �- ----X-I � J.Contractor's Name--- --------------------- ---------------------- ----------------- - ----------------- - -- - -- ------•--------------- Phone------- --------------•- `---- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ M tel rr�� ❑ Oh�r ❑ Number of livingunits: __!____ Number of bedrooms __tr f 'Number baths ___f___ Lot size Water Supply: Public system ❑ Community system ❑ Private Depth + ;o Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam g Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No E� New Construction: Yes Z/No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: '" (No septic tank or cesspool pe'rmitted-if public'jewer is.available' within 200 feet.)-61 ank- `Septic , pistance from nearest well_�4✓_---pistanrre frorr� fo tion___ ---.Mate ia� ' No. of.compartments__ f ISize �© Liquid d pit ------- 6------------CapacitY--Z--�t�� DisposeField: Distance from nearest well _ ----Distance from founclation„� __ __Distance to nearest lot lie � P Number of lines---------- ----- rr �_ ____Length of each line__�_�`✓__'_�'� Width of trench _____( •� ------ Type of filter materi q r - yp *(1_�r"i. Depth of filter material -------Total length--------0__�_Q. _________I_ Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot line__________._! ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----,------------------Depth---------------------- Cesspool: Distance from nearest well____________ ___Distance from foundation--------------------Linin.g_material__-._ ,._------------ Size. _Size: Diameter-------------=-------------------------Depth----�--------------- ------------ - ------ ------Liquid Capacity----------------------------ga III Privy: Distance from nearest well----------------------------------- ------------Distance from nearest building ❑ Distance to nearest lot line----------------------------------------_-_-- , Remodeling and/or repairing (describe):---------------------------------------------------------------- -------------------------------------------------------------------•--•-------------•-------------------------------------------------------- i --------------------------•-------------------------•-----------------------------------------------------------------•"---------•---------------------- - ------------------•--- ---------------•----------•------------ -----------------------------------•---------------•------------------•----------------------------------------------------------------------------------------------------------- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counts, ordinances, S ate laws, and rules and regulations of the San Joaquin Local Health District. (Signed) _ ----- iia ./ -Q ----------------- ------------------------•---------------------- ----------------(Owner and/or Contractor =-- gY� (Title)------------------ , _-: (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 .APPLICATION ACCEPTED BY---- -- ------ ---------------------------------------------------------------------- DATE Lj REVIEWED BY___________________•----- DATE------- - BUILDING PERMIT ISSUED---------------- DATE ------------------------------- -- Alterations and/or recommendations-------------------------------------- ` ja%S` -------------- !�----------------------------------- � . _ , . 0 - -- - ---- ------------------------ ------------------------------------------------------ FINAL INSPECTION BY:-------- --------------------------------------- Date " __ / SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreof Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 {