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IPermit No. �. APPLICATION FOR SANITATION PERMIT (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. �. JOBADDRESS A D LO ATION----I-_-��------ ------ -------- ------ -��"`"r--•----------------------------------------------------------------- ------ Owner's Name----- - --------- -- ------ ------ Phone----------------------------- Address------ ---•------------------------Address------ --- _-- --- ------- ----- ---------------------•--•----....------------------------------- -•---------------------•------•----------------------- -� Contractor's Name.-- - )r ------------------------------------------------------------------------------------------- Phone,��. _S'A� --------- Installation will serve: Residence PM_-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: �_ Number of bedrooms - Number of baths f--____ Lot size --- Q---. __]--aya--------------------- Water Supply: Public system A—C-0-mmunity system ❑ Private ❑ Depth to Water Table -Qr- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay e_-<10-60 ft-11ardpan ❑ Previous Application Made: Yes ❑ No few Construction: Yes ❑ No45�. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pernii+ted if public sewer is available within 200 feet.) Sept'. an Distance from nearest weh-----------------Distance from foundation--------------------Material---------------------- -------------------------- M No. of compartments------------------ -------Size.. _------------------•-------Liquid depth--------------------------Capacity----------------------- Dispos I Field: Distance from nearest well-----------------Distance from foundation-------------.------Distance to nearest lot line--------_--._-.-. Number of lines---------------- ----- - -----------Length of each line------------- - --------------Width of trench-.--------------------------------_ Type of filter material-------------------------Depth of filter material---- _----------------Total length----------------------------------------.. Seeps a Pit: Distance to nearest ------Distance omfo ndation-_-..3CI--._--.Distance to nearest lot line---- ----------- Number of pits.---/---------------Lining material- � --- -Size: Diameter4zlp.....,00 __Depth-.-�_Q--` ------------------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material-------------------------------------- Size: -----___-.-- ---.----------_-_-----Size: Diameter = Depth - ---- --------- - --- Privy: Distance from 'nearest well--------------------------------------------- ----Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line---------------------- ---------------_-------------------_--------- ---------------------------------------------------------------------- [� Remodeling and/or repairing {describe)--------------------------------------- -------------------------------------------------------- •----------------•-------- Q -- - - - - - - - - -------------------•----------------------------•-----------------------•----------------------------------------------- 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)-- - ----------------------------- -- --------------------------•--------•-- ----------------------- 'e 7 wt Contractor] 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 X1- ---------------------------- .-•---- ... ---------•--------------------- REVIEWED BY----------------------------- BATE - BUILDINGPERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE---- ---------------- --------------- Alterations and/or recommendations----------- -------------------------- -- ---------------•------------------------- ... ---------------------------------------------------------------- ------- ------------------------------ ---------• ----------...---------------------------------- ---- -------------- ----------------•----- -------------- -------- -- ---------------- '�---- FINAL INSPECTION BY:=----... -------------------- Date-------- ` -------------------------------------------- SAN ---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oek Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Ea-9-2M 145446 P'WDOD 12-s4