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APPLICATION FOR SANITATION PERMIT Permit No. ..........I....... (Complete in Duplicate) Date Issued Applical-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 Ordingrice No. 549. V/0-1 JOB ADDRESS AN OCATION -- ----------- ------ -------------------- --------�? Owner's Nam ----;R4 -------- ---- -- ------- --- --- -- --------- ------------------------------------------- ----------------- Phone--- -------------------- Address.- .... ....... Contractor's Name----------- ----------- ---------- ... ----------- ---------------------------------- ------ ------------------------------------ Phone---------------------------------- Installation will serve: Residence partment.House L] Commercial [—] Trailer Court L] Motel [] Other E] Number,of living units: Number of bedrooms -J. Number of baths I______ Lot size ------------ ----.---------_--_---------__-•____---_ Water ------------------------------- Water Supply: Public system Ej Comm-dnity system [—] Private-Depth to Water Table /.(-. ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E3 Adobe Hardpan ❑ Previous Application Made: Yes E] No New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 'MOsis?aInce fpmjoundq�ion----1-0--------M f - I Septic Tank: Distance from nearest well M- -------- a qria-- ---- - - ------------ 4------- / No. of comparfment1--. ---7A-- i,e-*A. X.7-Liquid clepth------- C a pa c!fy-.-7- s-,t�. Disposal Field: Distance from ne4r,�'f',7- lAef a a 12.n-- Imo4:� eil-i,dXA1- nce from found t- -.Distance to nearest I t line- Ar� Number of lines Type of filter ma-te-r-i-al-- ---- --- Length of each line---- ------Width of trencil- -- --------I------------------ of filter material---------- --;?------Total length------4-1-0--------------------- Seepage Pit: Distance t; nearest welf-----I----------------Disfance-from foundation....................Distance to nearest lot line_____._._________ ❑ Number ine----------------- Number of pits----------------- --Lining material----------.---.--------Size: Diameter------------------. --Depth..------------------------------ r Cesspool: epth--------------------------------- Cesspool: Distance from nearesf w6l-----------------Distance -from foundation....................Lining material__..___..__________.____----______.__. Diameter—' ----------------------�-.-D.W h--—------------------------------- ---------c --.-,Wd Sa,p --------------------_gals. acity Privy: Distance from nearest well-------------------------- --------- . ..........Distance from nearest building______.._____-________________.--_.----._. „ [] uilding------------------------------------ F-1 Distance to nearest lot line------------------------------------------------------------------ Remodeling and/or repairing6 ---------- -------------------------------------------------------------------------- ------------------------------------- -------------------------•---------•--• ------------------- --- --- ------------ ------------ --- ------------------- ---------------------------------------------------------------------- ----------------- --74- ------------------ --- -7-1--- __- -- ----------- ------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, Statelaws, and rule nd re ulafions of the San Joaquin Local Health District. (Signed)........ . ...... . .. .. ----- ---------:.--- -------------------------------------- --- ...................--(Owner and/or Contractor) By:------------------------------------ ---------------- ------- 11------------------------------------------------------------(Title)------------ -------------------------------------------- --- (Piot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------------- ------------------------ DATE REVIEWEDBY------------------------------------- ----- - ---- ------------ -------- ------------ ---------- DATE------- BUILDING PERMIT ISSUED. -- ------------------------ 0 ----------------------- DATE...._.----.1............ ------ -------- ----- ......------- Alterations and/or recommendations:-------------------------- ----------------------- ------------------------------------------------------ 7-------------------------------- ------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ --------I--------------------------------------------------------------------- -----------------------:------------------------------ ----------------------------------------I--------------1--------------------- ----------------------------------- ---------------------------------------------------------------------------------------------._...-•------------- -------------------------- ---------------------------------------- ------------------------------------------------------- ---------------------------------------- -------- --------- --------------- -------------------------------------------- ------ .............. 7 J, FINAL INSPECTION BY:.:--- --------------- -- -----r 7111111111--,"V Date-----------; - ...................... 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--v 145446 A7WCOD