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APPLICATION FOR SANITATION PERMIT Permit o. ____ - ----- (Complete in Duplicate) S/ Date issued -----------------__ Applica;ion is he 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 .. - !V- --------------------------------- Owner's Name---Z— --------- ---------------------- ----------- -------------------------------------------- Phone--------------------- -------------- — Address-__- ----=-•----------- -------- -------- ----•------•--•--........------ -------�---- ------------------------ - ----•--- ---------.....------..._-.- Contractor's Name - ------- • -- �'1-� ------------------------------------•----.-. Phon 'rs Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: : _- Number of bedrooms -,?_Number of baths /---_ Lot size ----------- Water Supply: Public system ommunity system ❑ Private Depth to Water Table J-!� 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 Tank: Distance from nearest well___-_--Distance from foundation.._. 4-� Material_' _ -------- No. of compartments---------A�-------Size---- - _Q•---Liquid depth--. ----------Capacity.. .1ro----___ Disposal Field: Distance from nearest well44 !__-Distance from foundation----/0__(___.Distance to nearest lot line--- �a__�.... Number of lines-------- ._... �-- Length of each line--a.0-------------------Widthrof.trench----Z_y------------------------ Type or filter material---lam___________Depth of filter materiaI_._.�'4 ----Total length-----� _-----._ Seepa-ge Pit; Distance to nearest well---- d_r ___Disf nce # foun ation-._. .G�_'___.Distance to nearest lot line_S -_- [, __` Number of. pits.__._.._.._______._Lining material_` _Size:,Diameter__ �.`.......Depth__a _�--_----_--__-_-._.- Cesspool: Distancefrom nearest well-----------------Distance from foundation--------------------Lining material-- --_____.____._-._-_-___- ❑ Size: Diameter---- --- - -------------- -----------Depth-------------------------- ------------�----Liquid Capacity-----------------------------gals. PrivyPriv Distance from nearest well-------------------------- __Distance'f'om nearest building. _----__.--__-----. -� : -------- - --------------------------------------------------------------------- 4 Distance to nearest lot line - ---- Remodelingand/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, St laws, and ru s and reuI tions of A San Joaquin Local Health District. (Signed)---- -- ----- -------------- - s --F.�___t.----------- ------- ---------------- ----- Contractor) Sy:.- --=---`------ - ---------------=-----------------------------------------ITitle) . --------. ---------------- (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----- . �----• ----- ----------------------------- REVIEWED BY-------------- --------------- DATE ------------------------------------ BUILDING PERMIT ISSUED-----=----------------------•------_� ----- - DATE------------ - --------` ----- ---•----------- Alterations and/or recommendations__--------------------- �__ /' r. `�5�7 I � t 4 9 FINAL INSPECTION BY:. - Date---------------------------------------------- SV\ SAN JOAQUIN LOCAL HEALTH DISTRICT I30 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E3__9-2M 145445 AT-DO 12-54 _ ,r d