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APPLICATION FOR SANITATION PERMIT Permit No. .: .L_3_Z [Complete in Duplicated � Date Issued __11/"__/S . 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 w'th ounty Ordinance so 549. JOB ADDRESS ANP LOCATI ' �� ' ---------------------- -- � Owner s Name---- --------------------------------------------------------------- -- --------------------------------------- ----------------- -------- ----------------- Phone Address - --•--- --------- ,------------------------ --------------------------------------------------------••-•--------- ---- -- / t Contractor's Name... - ✓--•----------------•---------------•--------------------------------------------------- Phon :_ '' •_ _f Installation will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths __/--- Lot size _r_ c `Q_�C_-!__ ____________.•------,_ Water Supply: Public system 4 -GImmunity system ❑ Private ❑ Depth to Water Table F0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes ❑ No TYPEOF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septics jank- Distance from nearest well__,______________Distance from foundation----------------.__Material .-_____.__--__._____.. ---______----._____. v ' No. of compartments Size -------------------Liquid depth--------------------------Capacity----------------------- isposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_.____---______-- .r x Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material ...____.__------------Total length------------------------------------------ Seepage Pit: Distance to nearest w 00 ell+-�s4____-__Distancem #�undation-_ __ stan�� to nearest lot line__�_.�e_.____. Number of pits_______ ___________Lining material_ /�i•�e�/Size: Diameter - -----Depth_ .. _.-_.---____.--_ w Cesspool: Distance from nearest well----------------- from foundation_-------------------Lining material------------------------------------- El Size: Diameter------ -------------------------------Depth--------------------- ---------------------- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest well -____________________---------------.---------Distance from nearest building------------------------------------------ 17 Distance to nearest lot kne----------------- ---------- ------------------ ••--------------------- Remodeling and/or repairing (describe):--------- 0 - -•-------------------------- -------------------•------------------------------------------•---•-----------------------------------------------------------•----------------------------•------------ -----------------------------------------------•-----------...-------------------------------•-----•- ...I---•------------------------•------------------------------------•-------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,�_afews, an . rule and regulations of the San Joaquin Local Health District. (Signed)-- - -- ----- ------- --�----- -------------------------------------------------[�br Contractor) BY• - _ _ - ------------------------------ --------------------------------------------(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--- ..- REVIEWEDBY---------------------------------------- ---- ------------------------------------------------------------------------------- DATE------- -----•------------••-------------- BUILDINGPERMIT ISSUED-----••-- ------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:.- --------- -------------------------------------------••-----------------•---------•-------- -------------------------------••------ -------------------------------- ---------------------------- ---•---------------- •------------------------------------------ --••-------------------------------------------•--- ----------------------------------- ------- ••---------------------------------------------------------------------------------------------------••-------- FINAL INSPECTION BY---------------- --------------------------- Date-------`L �66[J ----------------------------------------- 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 ES-54- 2m 74544e ATWOOO 12-54