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APPLICATION FOR SANITATION PERMIT Perm1,N (Complete in Duplicate) Date Application 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 LOCATIO --------! / - i ---------------------------------------------------------- ----- ---- - -- Owner's Name-----------------/------- L --- - Phone--------------------•--------------- -- ------ ---- - -------- - ------------ Address------------------------ -- -- --- ------' -- --- --- - ----�---------•----------- -- ----- - ----- -- - - -- - ------- - Contractor's Name------ -__ + -� ---------/-�-� --'- �t� Phone__ ��~ ! Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -/----.Number of bedrooms ftt_ Number of baths j__ Lot size ______ ___ ---------•-----__ Water Supply: Public system Community system 0 Private ❑ Depth to Water Table ________ 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 F] TYPE OF INSTALLATION AND SPECIFICATIONS: C (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �R Septic Tank: ,[, Distance from nearest weiLll Distance from foundation.Material-------------------------------------_---------- _ ❑�I-1 Tistance o. of compartments--------------------------Size-=------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field; from nearest well,**A .Distance from foundation___- --------Distance to nearest lot line__�r----- Nu _I Number of lines_______ ---Length of each line____, Width of trench_ -------------------- De th of filter material___ Total length--. .. _pe of filter material- p �rSeepage Pit: istance to nearest well- _ _�Q__Distance f qu tion_ 6 - -_.D'tante to nearest lot lines J__ umber of pits- --____Lining material_ ize: Diameter__ ______________Depth___p �j_ ___ __- ---Cesspool: Distance from nearest well_________________Distance from foundation____-------________-Lining:material------__----_________.___________Size: Diameter---------------------- ---------------Depth---------------------- ----------------------------Liquid Capacity--------------,-----=--------gaPrivy: Distance from nearest well-_______________________________________________Distance from nearest building______________- ❑ Distance to nearest loft line.-------- ---------------- -----------------------------------------------•--------------------------------------------------- Remodeling and/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, State laws, a rules and regulation f th San Joa uin Local Health istrict. I (Signed) ��1 ------- =- ---- ----�Gf_t-fir Gh (Ow rand/ Contractor) ! _ ----- Title -------- By:------- ---�--- - -- ---------- -------------------------- - ----------------------- { ) -- ------ --------------- ----------------- (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 w APPLICATION ACCEPTED BY- ------------------ DATE �� -------------------------------------------- - 6 -------------------------------------------------- ✓ RIrVIEWED BY------------------------------------ ------�`------------------ DATE ----�- -- ------------------------•--------------- BUILDINGPERMIT ISSUED------------------- ------- - --------------------- ----- ------------------------ ---- DATE------------��_- ----------------------------- Alterations and/or recommendations: --- ------- -------------------------------------------------------- -------•--=------------------------•------- ----e1__-- ( / �A -� w - 2b -_� rs of ~-- i �` •-•-------- -----------------------------------------------------------------------------------------------------------------------------------•-•-------------------- FINAL INSPECTION BY:----,);V./ Y_-____ __ _ ________-- -------------------------------------------------------------- ------------------------------------------------- --------------.---------------------------------------------------------------------------------------------- l^ !/ - --------------- Date---=------�----------- ------------------------------------------------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore $free+ 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California • ES-9-2M 8-51 Revised W-2100