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APPLICATION FOR SANITATION PERMIT Permit No. _6_3 2_0 (Complete in Duplicate) (I /-� Date Issued ______ 1 S.__.___ 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. JOBADDRESS Al LOCATION .- 1------- --- - - ----- -------- ----------------------------------------------------------------------------------------------- Owner's Name 1__tv4 ' = ---_------_-•----------- - Phone � �~y��Address------------------� ��------�-- -- , ----- ----- -----••----------------------------------•--•----------------------------------••------•--------------------------------- Contractor's Name--------------- l All ' - '- --- -------------------------------------------....-------------•------------------ Phone---•-------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ FF 1.40 e Number of living units: ---I-___ Number of bedrooms -m?-. Number of baths __�i Lot size -----._.!_U/--X____[ .4_{-------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ _____ ft. Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam Clay Loam [lay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No 2r,", New Construction: Yes [� IVO ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if+ public sewer is available within 200 feet.) Septic T k: Distance from nearest well__. ____Distance from foundation---.-C-d---------Mat I------- ______________________ �� No. of compartments_.____________________Size---��__�,? ------Liquid depth--------- ----------------Capacity-----d!�- _-- Dis os Field- Distance from nearest wel ..-ATA—Distance from foundation____]0.-..___.Distance to nearest lot lin p P r d*0♦ ?0' �r Number of lines______________ ----------____- Length of each line________ _____.W,dth of trench.-_______ _____------------ ------- Type of filter mate riaI__�Lt__�TjA.Wepth of filter materia L__.___��_______-_Total length---. - --------- ___-_�_. __..__.. Seepage Prr: Distance to nearest well_____________________Distance from foundation-------------------_Distance to nearest lot ini'e_______.___-_____ 90 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth-------------------------------. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______._____--__.---_-________-______ ❑ Size: Diameter--------------------------------------Depth -------------�,,--------------- ------- --------------Liquid Capacity----------------------------gals. .t\ W Privy: Distance from nearest well_---------------------------------____..------Distance from nearest building-------.-.--_--_______________.__________ ❑ Distance to nearest lot line---------------- - ---------- ------------------------------•----•---- --------------------------------------------------------------------- Remodelingand/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)-- .tl� – - --ace, _____________________________(Owner and/or Contractor) By:--------- - -------------------------------•---------------•--------------------------------------------------------------------(Title)------------- -----------------------•-------------------------- (Piot plan, show ng size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------- - -- ---------- ---------------------------------- ------------------------------ DATE-- ------------------------------------------ REVIEWEDBY-------- ------------------------- -- --- ---- ------------------------------------------------------------------- DATE- �.. BUILDINGPERMIT ISSUED------------ ------- ----------------------------------------------------------• DATE---------------------- — -• ---•----- Alterationsand/or recommendations:------------------------------------------------------------------------------------------------....-----------------------_------------------------------------ ---------- ---------------------------------------------------------------------------------------------------------------- •----------------------------------------------------------------------------------------------- ----------------------•----------------------------------------------------- --------------- --------------------------------------------------------------------- -------------------------------------------------------- ---------------------------------- ---------------------------�------. ----------------------------------------------------------------------------- --------- ---------------------------------------- FINAL INSPECTION BY--------------- ----------- -------- Date.- f/ -------0 -------------------------------------- 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 E5-9-2M Revised W-2100