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APPLICATION FOR SANITATION PERMIT Permit No. ..... .3. {Complete in Duplicate) y 7 Date Issued ....... I jSZ 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 Ordinance No, 549. JOB ADDRESS AND LOCATION --------- F Name.._. . one ---•----.... j Address ll C� Contractor's Name _ ------ Phone. --- Installation will serve: Resident//e 2LApartmenf House ❑ Commercial ❑ Trailer Court E] Motel E] Other F ,1.. Number of living units: .-_ Number of bedrooms .-v.. (umber of baths 1------ Lot size -.-..,�- Water Supply: Public system XLCommunity system ❑ Private ❑ Depth to Water Table .l J ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ . Clay-E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No P -New Construct ion:-,-Yes jU__No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: , stance: from nearest well.................Distance from foundation--------------------Material..._--------...-...----------- ❑ of compartments------ -----------------Size-------------------------------Liquid depth--------------- Capacity Disposal Field: J istance.from nearest well------------------Distance from foundation....................Distance to nearest lot line-----.----------- lines-------------- .___...-.lines-------------- -rl----------------Length of each line---------- ----- ----------- Width of trench---------------------------------- T pe of filter material ---------------Depth of filter material---------..,__---------Total length------------------------------------ Y` / Seepage Pit: Distance,.to nearest well.... 47._\A.--Distance from founds ion..._�_..�7._._...__.Distance)o nearest lot �_ P /------------- g Z . Number.of its..._. Linin material_ _.-.-.. Id Diameter._- f ' Cesspool: Distance from nearest well.............._.Distance from foundation------------------- Lining material------------------------ Size: Diameter--------------------- ----------------Depth--------------------------- --- - - -- ------ --- --Liquid Capacity- •------------------------gals. Privy: Distance from nearest well--------------------------------------------:____.Distance from nearest building----_--------------------- ---.--..------- ❑ Distance:to nearest lot line----------------------------- •- ----------------...------------------------------------------------------•------------------------------------ Remodeling and/or repairinrg (describe)---------------------------------------- ---------------------------------------------------•--- -------------•------------=---••---------------•-••----- - -------------•-------- ----------------------------------•---• ----------------------------------•------------------ ----------------------•--------•------------------------ ------------------------ ------------1----- ___'_1---------------------------------------------------------------------------------------•--------------------•-----------------------...-----•----------------------------- -- ------------ --------- -- -•---------- -----------••-------------------•------------------•-----•-----------------------..-----•----------.....----------------------------------••----•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stt laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----. ---------- = Com-- ----`---- --- ------- ---------------------------------------------------- -- -------.(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 reverse side). Fpa DEPARTMENT USE ONLY APPLICATION ACCEPTED BY •- ----- DATE �a = REVIEWED BY---------------------- = ---------------- DATE---- BUILDING PERMIT ISSUED_---------------------------- DATEf ... - - DATE-- --------- --- � -- Alterations and/or recommendations:.................... _ u / --------------------------•------= ------- -------- : � ------------- ---------- . ---- ----------••----------------- .................................... .. ....` ----------- ---- - �-..� .__.C1ay ti% .-_-.----- -_-...-......_.- __-..... ---------------------------------------- ---- ------------------------------------------- .................................... ..-_.......-i.....-.-..............-..-.--......-----..------------- ---------- FINAL INSPECTIONBY:.. f.. := ---- -- - ----------- Date_ " s SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California N 145446 ATW000