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APPLICATION FOR SANITATION PERMIT Permit No. . _..7. ...� 1 (Complete in Duplicate) 3 Date Issued ___(.__ _.C�� Applica+ion 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 rdinance No. 549. JOB ADDRESS AND4LCATION--_-,.-- -1 - •-------------------------------------•---._.-..------------------------------ Owner's Nam e____________ --- x�- ----------------- - ---------- - Address.---------- --_ ` Contractor's Name------------�---- - ------s --------------------------------------------------------------- Phone---/ !.__�P_ ----- Installatiion will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/___ Number of bedrooms __ __ Number of baths _-__/-. Lot size __. Q_ _ _-.�Qd ________________________ Water Supply: Public system Community system [I Private ❑ Depth to Water Table __Yl ft. Character of soil to a depth of 3 feet: Sand Gravel L] Sandy Loam E] Clay Loam ❑ Clay E] Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No New Constructio Yes ❑ 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_________________Distance from foundation--------------------Material----------------------.--_-__..._______._.______- ❑ �t,e.o � No. of compartmenfs--------- - -------------Size...-•---------------------------Liquid depth-------------------------Capacity------------- -------- \ 1 Disposals Field: V Distance from nearest well-----------------Distance from foundation________'________.Distance to nearest lot line________.___-._-. ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench.---------------------------------- n Type of filter material________________________Depth of filter material___________________Total length____________-_--__--_-_---__-_________-_._ ry .,2d Seepage; Pit; Distance to nearest well--------_—-------Dist e from ou ati n---- to nearest lot liner______________ Number of pits_______]-----------Lining mate ial_C-e.-_----- ----S' : Diameter_---.�3`-._____Depth----4S_______.________ Cesspool: Distance from nearest well-----------------Distance rom foundation--------------------Lining material__._______________.____..____-.--_. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------- 1771 Distance to nearest lot line--------- --------------- ------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------...------------------------ ----------------------- - - - -------------------------------------------------------------------•----•-------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. (Signed).------------------tydf ------- ----------- -- ----------------------------------------------------------------------AL—r and/or Contractor) B'Y:--------------- --------------------------------------------------- -------------------(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--- -- ----- ------- ---) 9 L -' / ------------------------- DATE_ -------------------- REVIEWEDBY-------------------------------- ------------------ --------------------------------I-------------•--------------- DAIZ------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------- --------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------.------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------- •----------------...--------------------------------------------------•--- ----------------------------------------------------------- ------------ ---------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- --.------------------------- --------- -I----•---- ------------ -•------------------ -----•--------------------------------------------------------------•-------- FINAL INSPECTIONBY:--------Y---------------- ------4'--------------••-- - Date_----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streef :Stockton, California Lodi, California Manteca, California Tracy, California ES---9--2M ; Revised W-2100