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APPLICATION FOR SANITATION PERMIT Permit No- --------- ------ (Complete in Duplicate) Date Issued ---- � .. i Applica"ion is hereby made to the San Joaquin Local Health District for a permit to co truct and install the work herein described. This application is made in compliance with County Ordinance.No. 549, a I , JOBADDRESS AND LOCATION---- --.- ------ ---- ------------ - -�------ --- ------ -- -- --------- ------------- -------------------------------•------- Owner's Name-- ------•• ---•----- ---------- - --------•-------- -------- - --------------- ------------------- ---- Phone------------- ---------•------------ Address --..� r ------- ---------------- --------------------- ------------------•--------------------------•----- 1 Contractor's Name----:- --------- '--------------- ---------------- Phon Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . g `_ ___ Number of bedrooms _.� Number of baths/---- Lot size .-► ...-_.__.. �G c. Number of livor units: •'��------------ Water Supply. Public system ommunity system ❑ Private ❑ Depth to Water Table�_5v ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe f-F-Fardp o Previous Application Made: Yes ❑ No�—� ew-Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p from n ....... No, of co -------------------- Material....-..-_______..--------------._-_------------- Septic Tanl• � Distance earest well ..........Distance from foundation ,mpartments--------------------------Size------•-----------------•-------Liquid depth----------------- -- - --Capacity-------------- -------- Disposa .Fiel _ Distance from nearest well.----------------Distance from foundation--------------------Distance to nearest lot line.-......_..._..-- Number of lines-----------------------------------Length of each line---------------------------.-.Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------- - � r Seepage Pit: Distance .oto nearest well Distance m fou dation_/-�-_!.-..Distance to nearest lot line...-._..._ Number of pits---_/-----------Lining material._. YSize: Diameter-M. Deptn_. �.............__-_. Cesspool: Distanceifrom nearest well.................Distance from foundation............-_.....Lining material......-- -------,__._....--------.._ v ❑ Size: Diameter--.----------------------- ------------Depth------------------------- ------- -------- -------Liquid Capacity----------------------------gals. Privy: `from nearest well----.- .--------- --------------------------------Distance from nearest building----.----_------------=--------= ❑ Distance'i'to nearest lot 4ine-------- - ------------------•--------------------------------------------------------------------------------------------------- - ------- 11 Remodeling and/or repairing (describe)---------- ------------- - --------------••-----------------------------------------•-------------------------------------------•------------ ------------------------------•------------------------------- -------------------•---------------------•----------_- ------------------------ - ----------------- -i-�---------------------------- ------------------------------------------------------------------------------------------------------------------------------ Ihereby certify thatave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, an '`rules and regulati ns of the San Joaquin Local Health District. 7t `t 7t %. Contractor (Signed)---- -----�---� ----------------------------------------------- ^ - -.-- ---------------------------------------------------------------ITitie) �' ------------------------ (Plot plan, s owing size of lot, location of system in relation to weals, buildings, etc., can be placed on reverse side). iN FOR DEPARTMENT USE ONLY IBY----------- - -- -------- - --------- -----------------------••----------------------- DAT ------.-..--------------------------------------- APPLICATION ACCEPTED, DATE---- ----- ------- ----- ---- --- BUILDING PERMIT ISSUED- REVIEWED BY----------------------- ----------------------------------------------- -•---- DATE------ ------ --------------------- ---------------------• Alterations and/or recommendations:------------------ .........."-------------------------------------------------------------..,..--- ------ = -----------------•-------- }---- ----------------•----------------- -------------------------- _ ..!'- ----------------------------------------------------- -----------------" ------------------ ----" :- ------' -- � - ----- -- " ---------------- ------ Date-------� --•----- --- -- FINAL INSPECTION BY. I �I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California II ES-9-2M 145446 ATW00- 12.54