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APPLICATION FOR SANITATION PERMIT Permit No, ,:�:r.A..q..7-.. (Complete in Duplicate) Date Issued 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. JOS ADDRESS AND LOCA ON_________ ___ � _.___ ---------- --•- •-------------------------------------------------------------- 0 ------------------ --------------- Owner s NameQ..+C *�•!t - ------------------------------------ Phone----------------------------------•- Address--------------------------------------------------- = ------ -.._-.---- ------------------------•---•---•--------------------------------- Contractor's Name--------------------------------- r ',----- ---- Phone----------------------------------- Installation will serve: Residence rtment House E] Commercial E] C��u Trailer� rt ❑ Motel E] Other Number of living units: um _ ber of bedrooms -------- Number of baths Lot size ----------------7 __+____._._ Water Supply:' Public system ❑ `Community system E]-'-Private Depth to Water Table ------_. ft. Character of soil to a depth of 3 feet: i Sand ❑ Gravel El Sandy Loam El Clay Loani ❑ Clay E] Adobe�,�.Ha pan El Previous Application Made: Yes ❑ No �'i�ew Construction: Yes [LINP.-O TYPE OF INSTALLATION AND SPECIFICATIONS:' _ (No septic tankorcesspool permitted if public sewer is available within 200 feet.) r Septic Tank: -Distance from nearest well-----------------Distance from foundation----...-------------Material------------------------------------------------- 171 'No. ---__-._-_._--_-..---_._----------------------- No. of com art5ments___.-:-.-------------------Size----------•---------------- ---Liquid depth-------------- - --------.Capacity Disposal Field: Distance from nearest well __:Distance from foundation--------------------Distance•to nearest lot line----------------- hN Number of lines----- ----'--.-.- ------ ❑ --_-._--Length of each line-------------------------------Wid+h of french----------------------------------- CA Type of filter material------ -- ---'---I._.--Depth of filter material--------- -"-----Total length-----.------------------------------------ 4- Seepage Pit: Distance to nearest,well7__-.<_,.-... ___.:Distance from foundation___+p........:.....Distance to nearest lot line---__.--_-___.-__ ^•� ❑ Number of pits----------------------Linin4 aterial---__.__-._-__ ____.Size: Diameter__-_-- --------------------Depth -- ----- _- tA �r,{ Cesspool: ;Distance from nearest welh->_U_: Distance from foundatian__'/' fining material__.. -- - - -- °' _ — ]Size; Diameter----- -- _. De th _ _ g _Xa,- -------_ p,. -_ _---:-- Liqusd;�Ca,pacitY: :_ .:gals_;_ �..._ Privy:'. Distance from nearest well-_-____---`---------------------_--_-__________Distance fr m nearest building------------------------------------------ ❑ Distance to nearest..lot line----------------------------------- ------------------------------------------------ -- �` -•'o- Remodeling and/or repairing (describe):-- ------------ ----- ---------- ------- -----••-•-•-•--•-------------------------•- ---- --------------------------------------'----------------•----------------------•---------------------- ---------------------,----------•-----•----•-----------------------------------•--------------------------------------- f I hereby certify that I have prepared Phis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of file San Joaquin Local Health District. (Si ned -" 9 )•--------------------•------•------------------� �1.-e..r11 ---------------------(Owner and/or Contractor) 1 By:----------------------------- • i-------=----••---•----(Title).-------------------------------------------------------------- (Plot plan, showing size of lot, location of sysfeni"in relation to wells, buildings, etc.,can be placed on reverse side). FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY `-------------------------------------------- DATE.------------ REVIEWED BY-------------------- - ---------- DATE------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE_----------------------------------------------------------- Alterations and/or recommendations:--°---------- --- ------- ----------......•-----------------------------------........ -•-----•--------------••-------------------- F -------------------------- ---------------------Y-------.-------------_--------------------------------------------------------------.----------------_----------------------------------------------------------------- ----------------------------------- 1 =i= r� Date = r FINAL INSPECTION 'BY:.--"-"-= = -------- --- = -----------•----------------------- p -A - SAN JOAQUIN LOCAL•9EALTH DISTRICT 130 South American Street 300 West Oak Street 132 SyceFnore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M Revised W-2100