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V1 APPLICATION FOR SANITATION PERMIT Permit No. v (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor rein described. This application is made in with County Ordinance No, 549. JOB ADDRESS AND LOCATION... -A _- ?'�a.L -Q�.. 4�- .�,� � Owner's Name - T'__-- * ---- � ------ Phone Address t#4 �._�u_--� ---- -- ------------ -•-------------- ------------------------------------------------ ------- ----------------------••---- Contractor's 'Name ------------ ------ Phone ---------- --y will serve: Residence X Apart ent House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: A____ Number of bedrooms _J___ Number of baths ---I_--- Lot size ___ ______ ____�___ _ l � Water Supply: Public system ❑ Community system ❑ Private [K Depth to Water Table 1------ 'Character fl-,Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ Previous Application Made:. Yes ❑ No X New Construction: Yes ❑ No [)( g 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--------------------Material ______.: ❑ No. of compartments--------------------------Size---------------------------------Liquid depth-------------------------Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation-------_---------_Distance to nearest lot line----------------- ❑ Number of lines------- -------------- -- ---------Length of each line----------------------------Width of trench.-------- . i Type of filter material-_______________________Depth of filter material__.-___._____.--------Total length------- -- C _Cp Seepage Pit; Distance to nearest well______________________Distance from foundation-------------------- to nearest lot iine------ ❑ Number'of pits----------------------Lining material-----------------------Size: Diameter------- Depth l7 Cesspool: Distance from nearest well____- -_ _Distance fro foundation__._ 0-____.Linin material - "_ Size. Diameter. -- -- "" p_ _ _ ;Liquid,CapacitY �.l -• -•- als. _ Privy: Distance from nearest well_______"________________'__--_-_____.._____.___-Distance from nearest building ❑ Distance to nearest lot line------------------------- . .. I Remodeling and./or repairir4q describe]:______ _____- --" p =`'�'�---mss ------- • ( --1------- *. a --- --- -- :-- - ! hereb cert�f h I Davey y preparedlicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Si ned g )----------------- - ----------------- -'---------- --------------------------------------------(Owner end/or Contractor) By:-------------------------------- ------------- ----------- Tale (Plof 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:_____ _____________ ------ -----------------------------------••---------------------------------- --------------------------------------------------------------------------- --------------------------------------------------'---------------- .. [ FINAL INSPECTION BY:---:__-_........:..... .... rr>�c}j ------------- ----------- Date--- ------- SAN -----SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 I r