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'meq-(�-----� 6^` l`I APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _____ t y q 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. E JOB ADDRESS AND LOCATI N / 0 .1-- ------- ----- ----- --- - ------------------------------------------------------------------------- Phone------------------------------------ Owner's Name--------- ------ ---�- - -•--------•- - ----�- Address-------------------- •---------------------------------------------------------------------------------------------------------------- Contractor's Name--------------- Phone Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other l� Number of living units: -1___- Number of bedrooms -_- -- Number of baths/_---- Lot size _______4972--�--(--,L��--=�?---------•------- Water Supply: Public system omm fy system ❑ Private ❑ Depth to Water Table _______ ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe� 'dpan ❑ Previous Application Made: Yes ❑ No -E?--1 lew Construction: Yes 94—we-B— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer is available within 2Q0 feet.) Septic Tank: Distance from nearest well __� Q.Distance fro undat�__ - Materi I_______ ________ �/ No, of compartments--------- n Size /1 '� Liquid d h Capacity DreposaI Field: Distance from nearest wel�/_�___ .Distance from foundation---� _-- - .Distance to nearest lot line__- - - Length of each line I Number of lines------------ _ �_ - _,Width of trench-__,�___ _ Type of filter material___' :_. -Depth of filter material_____ ______Total length------_- --- _ _ - Seepage Pit: Distance to nearest well---------------------- from foundation___________________Distance to nearest Ibt line__(_J__�_______-_-- ❑ l size: Diameter Depth Number of pits--------- ------------Lining materiaC Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______.____.-___________________--___- ❑ Size: Diameter---------=---------------- •------ ---Depth- ------------------------------------ ----------.--Liquid Capacity----------------------------gals. :-- :r. Privy: Distance from nearest weft------------------------ ------- --------------Distance from nearest building=___'-------------------------'----------- ❑ Distance to nearest lot 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, d rules and regulations of the San 1.9acluin Local Health District. (Owner Contractor) (Signed)---- '------ �- (Ow and/or tor} By:-------------------------------------------------------------- - Title ------------------------- - - (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 APPLICATION ACCEPTED BY------------------- ---------------------------- ---------------------- DATE `"" --- ----- - -- - REVIEWEDBY-------------------------- - - ---------------------------------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE----- ------------------------------------------------------- Alterations and/or recommendations-------------------•---- ---------------------------------------------------•----------------------•--•---------------------------- ------------------------------------- ---------------------------------------------------------------- 4 _____________________________________________ ---------------------------- -------------------------•----------------------------------------------- w _____________________--------_-----------------.------- -------------------- �. Dale-------- ------77� ------------------- FINAL INSPECTION BY--------------- ---- 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-9--2M 5-51 Revised W-2100