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APPLICATION FOR SANITATION PERMIT Permit No. -------- --1--`� (Complete in Duplicate) Date Issued` -- �/ 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 rdinance No. 549_ I.JOB ADDRESS AN LOCATION ---1-_D _bo------------------------------------------�------------------------------- ------------------.--------------------------- -� . Owners Name ' --- = PhoneZ_-_7___' {�... Address ' ------------------•----------------------------------------------------------------------------------•------------------------------------------------- Contractors Name--- ---�-------- ----- - --•-- --------------------------------------- - ----------------------- -----------------------•------- Phone------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Molk] Other ❑ Number of•living units: ___�__. umber of bedrooms ___I____ Number of baths ---�__ Lot size __-�_�.______X_.-f1,--_________________________ Water Supply,: Public system 4Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand.0 Gravel ElSandy Lo;PNo ' Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes El No QNew Construction: Yes ❑ TYPE OF'INSTALLATION AND SPECIFICATIONS:' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q ' ista ce fro un V __-_ , yja��d_ o - Septic ank: Distance from nearest well-) R, � f}o at�on__________ ____ _ Mat1er�al�____.___-_._____ Ef No. of compartments_____'__ _ ,!___---- -Size-C __X-_ -- ---Liquid dt�h_________rC----_______Capac __ -___ O Dispo Field: Distance from nearest well__ -Distance from foundation_--_ _____.Distance to nearest lot line_.- - � Number of lines----.._.._-_• . ----------- Length of each line------------------ --e -----Width oftrench----•-jj�•-- 1------------------ Type of filter material _41'�Length of filter material______1-- --------- otal length________---LI_: __________________ Seepage Pit: Distance td.nearest well----------------------Distance-from foundation--------------------Distance to nearest lot line----------------- 171 Number of pits-- ------------------Lining material----•------------------Size: Diameter-------•----------------Depth--------------------------------• Cesspool: Distance from nearest well-----------------Distance. from foundation--------------------.Lining material___________.__-----_________________. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity.---------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------..._-___________:_________.- t ❑ Distance to nearest lot line------------------------------------------------ --------------------•--------------------------------•-•------------------------------------ Remodelingand/or repairing (describe):-------------------------------------------- ------------------------•----•-----------------------------.._.......-.------•---------------.-.....---•--- 4 -----••---------------------------•------------------------------------------•-----------------------------------------------------•------------------------------------------------------------...... ----------------------------------•---------•------------ ------------------------- ---------- ----------------------------------------•---------------------••------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws-,7and rules and regulations of the San Joaquin Local Health District. 1 � (Signed =- f-- •- {Owner and/or Contractor( By. -------------------- -------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing's6 of lot, location.of system in relation to wells, buildings, etc., can be placed on reverse side). i i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------------------ ------------------------------------- -----•------------ DATE_ REVIEWED BY----------------_--- DATE BUILDING PERMIT ISSUED ----- DATE-------------q-S--------------------------------------- Alterationsand/or recommendations---------------------------------------------------------------------------------•--------------•-- •-•-------------------------------------------------------- ------------------------------------------------------------------------------------------•--------------------------------------------------------• -------------------------------- -------------------------------------- ------------------------- Date------ r_ f - FINAL INSPECTION BY--------------- - ------ --- 1�° - 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 i ES-4-2M 8-51 Revised W-2100