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APPLICATION FOR SANITATION PERMIT Kermit No. Z--.�-a--/ (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. JOB ADDRESS AND4LOCATION-- - _l. __ + A Owner's Name :..- Phone-------------------- Address.-•-- .. ---z` Contractor's Name ------------- Phone----------------------------------- t Installation will serve: Residence (go Apartment HouseCommercial E] Trailer El Court Motel Otherf E]__ Number of living units: . �Number of bedrooms------ Number of baths X_ Lot size f Water Supply: Public system V Community system ❑ 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 [k New Construction: Yes LJ No ❑ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) UJ Septic Tank: Distance from nearest well--;--------------Distance from foundation--------------------Material ___---.--.--__._.--.---__.--------.__._-------. W No. of compartments Liquid depth ----Ca Capacity LD P q P. P Y Disposal Field: Distance from nearest well-.---------- Distance from foundation------------- Distance to nearest lot line----------------- ❑ Number oilines----------------------------------Length of each line-----------------------------.Width of french----------------------------------- S Type of filter materiaf-------------------------Depth of filter material----------------------- length--------------- 0 Seepage Pit: Distance to nearest well------------------_--Distance from foundation----__.--....._-..Distance to nearest lot line..----------.---_ ❑ Number of pits........... Lining maforial-----------------------Size: Diameter-----------I----------Depth-A.----- ------------------•- • 1� Ces� Size: Diameter i-cm nearest we&0- istance from foundation-f_19` Lining material-N-4,6 ----P $4 %---- --- -------- epth----------- ' Liquid Capacity - �1 _ gals. 1 Privy: Distance from nearest well----------------------------------- -----------Distance from nearest ❑ Distance to nearest lot lire--------------- ------------------------------------------------------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)_ --------------- - -- :--------(Owner and/or Contractor) SY---- -••- ---------- ------ --- ---------------------------• -----------(Title)----------------------------------------------------------- --- (Plot plan, showing size of'lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- DAT REVIEWED BY-------------------------------- ----------------- ------- ------ N. DATE----- - ----------- --------------------- BUILDING PERMIT ISSUED---------- t '1 - DATE. Alterations and/or recommendations:--.. --------------- W !._ --�1-� 4......-------------- '� �----------------- ------------------------------- --- ------ ------------------------------ ------------- --------------------- --------------------------------------------------- --------------------------------------------------------------- ----------------------------------------------------- ----------------------- FINAL INSPECTION BY:___----------- ------------------------------------------- Date------------------------------ SAN ---------- /SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 149446 ATWpgo 12.54