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APPLICATION FOR SANITATION PERMIT Permit No. --/ T..�..� (Complete in Duplicate) . Date Issued 2!Z -- 17 0 -(0. 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 compliant_e. with County Ordinance No. 549. JOB ADDRESS AND CATIONj % _ --------- --------------- - Phone Name----- ----- - ------- ----- --------- --- ------ ------------- ------- Address -- •----•----I. -•--- --------------------------- •--------------------------------------------------------- Contractor`s Name---------• ---•------- --------- - ----------------------------------- --- Phone----------------------------------- Installation will serve: Residence Apa meat House E] Commercial ❑ Trailer Court E] Motel ❑ Other L)Number of living units: ____.__ Number of bedrooms __Number of baths ___I___ Lot size ___-_��_______________________ Water Supply: Public system ❑ Community system ❑ Private;?fl Depth to Water Table .351 77. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 14 New Construction: Yes k I No ElPHA/VA: Yes E] No l 1 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 0-_-4Distancg from foundat`i' ------.M terjal ,P - � tNo. of compartments.__._._�.__.__Size...r...�`1_Q. NLiquid depth_ .�_/___Capacity_____ «� Disposal Field: Distance from nearest wel__._6__Q__;Distance from foundation___I�0-.._...D`istance to nearest lot line.__.[__:-____. Number of lines---_---� Length of each Iine---------1 �¢__.____r�Width of trench------- '________________ Type of filter material-_ A_ Depth of filter material__________ _,_.__Total length_______1_6__0____r(____-____ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.____________._ ❑ Numberof pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth-----------------------"--------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------_--------_-----_--_---_ ❑ Size: Diameter---- -----------------------------Depth----- ----_----_------ ---------------------LiquidlCapacity __gals, Privy: Distance from nearest well ------------------------------------Distance from nearest building------------------------------------------ Distance __ __ _____ -Distance to nearest lot line------------------------------------------------------------------------ ------------------------------------•-------- ------ {I Remodeling and/or repairing (describe): ................ ------------------ --------------------------- ------ ----------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------- . ---------------------------------------------------------------I--------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State i s, and rules and r gulations of the San Joaquin Local Health District. ,_ ,�(Signed)----�`-�� _ =•. -- -- ----------------------------------------------------------------------------------- --- -(Owner and/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 recomm nplatians: ---- ------------------------------------------------ ------------------- ----•-••---------------------------- -- -- ---------------------- ------- -• --------�--- ��' '` �--= -- -- -------- -��AW------ 4G'------------------------------------- �'�'�� --------- ----------------------------------------------- ---------------------------------------- --------------------------------- --•--------- •-----•----- -------------------- -------------------------------------------------------------------------------------------------------------------------------------- �/ / yC__ ________________________________________________ FINAL INSPECTION BY:•----- ---- ----------- --------- --- ---------- Date. --- -------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revised 1.57 F,P.CO. 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