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APPLICATION FOR SANITATION PERMIT Permit No. .__;?y,/ S— ................ (Complete in Duplicate) ] / Date Issued p Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and ins�II the ork herein described. This application is made in compliance with County Ordinance No. 549, r f JOB ADDRESS AND LOC j.ON / � - Owners Nam ; �� l Address .f.-� --- --- A Contractor's Name------•--- csr ----- -------- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial �.Trailer Court ❑ Motel ❑ Other ❑ �-- Number of living units: -------- Number of bedrooms -------- Number of baths -mot size __- �t - ----------------- 1 Water Supply: Public system;[] Community system ❑ Private �L Depth to Water Table --V,6ft. �} Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan P I Previous Application Made: Yes ❑ No �4_ New Construction: Yes' - No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__,__. i?_:_-Distance-from foundation= _---.Mate rial----jlfLC_ZE__ ________ _. Q No. of compartments---,_ -------------Size-----~-' ---fL_ - --Liquid depth--___(e_ --------------Capacity:---- - ------ f � f Disposal Field: Distance from nearest well---- .-.-..Distance from foundation__e"' -------Distance to nearest lot line�� [f� Number of lines-----'---_/--------------------Length of each line-------- -- r/--.Width of trench------- Q------------------- Type of filter material--- Depth of filter material--- _ -------Total len gth--------C'ZZ---r ---___ Seepage,Pif: Distance to nearest well__`�Q.-.__-__._Distance from foundation-__ _ -------Distance to nearest lot line- Qi Number of pits------ -------------Lining material�Ci-�ze: Diameter---_�,��'�..Depth. Cesspool: Distance fi:om nearest well-----------------Distance from foundation------------.-------Lining material---------------------------_- Size: Diameter------------- - - -----------------Depth------------------ _ ❑ .. - --� .-...__. �-..., .._.�.-. ..._....._.-....._...��..,.-- ... -:.Liquid -Capacity ----,-:------------------ - Privy: Distance rom nearest well-------------- -------------- ---------------.-Distance from nearest building------------- ----- -_ ❑ Distance to nearest lot line...----- --------------------------- -------------•------------- Remodeling and/or repairing (describe)------------ ------ --___--------------------------------------------------------------------- ---4 ------------------------------••------------------••------------------------------•--------------------------•-----------------------------------•-----•------------------------- 1 - ---•--------------------------------------- I hereby certif that I have prepared this application,and that the work will be done in accordance with San Joaquin County ordinances, Stat a s, and,rules and regulations of the San Joaquin Local Health District, I (S� ned .g )--------- --•-�� ----711;�---- --- ---- - -- ( rand/or 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------ -- { REVIEWEDBY - ------------ - --- - ----- --------------------------------------------- DATE = BUILDING PERMIT ISSUED---------------------------------- ---------------------------------------------------------- DATE----------------- - -- Alterations and/or recommendations:- ------------------------------------------------------------•-------------�\� ----------------------------------------------------------------------------------- -------------•---------------------------------------------------••--------- ------------• ----------------•- - - -------•--I---------- --------------------------------•---------------- ---------•---------- ------- -----------•-----••------ -----•-•--------- -----------•------=---------------------- ----•----- ---------------------I-------- --------------------------- ------------ -------------------------------------- ------------------- ------ ----------- ---------------------•-------------------------------------------------- z7 .l_ FINAL INSPECTION BY: ------------- Date. �---------- ------ ----- ------------- 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-3-21A 145446 aTwoo" 12-54