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APPLICATION FOR SANITATION PERMIT Permit No._&Y-/---- (Complete in Duplicate) Date Issued,___/ Y� Application is hereby made to the San Joaquin Local Health District fo a permit to construct and install the work herein described. This application is made in compliance, with Co my Ordinanc No. 491 JOB ADDRESS D ------------ ----------------------------=- Owner's Name ----------- ----- -1&1) 0------ --- --- ------ -- --- Address---0_11-6 , - one --------------------------------------------------------------- Contractor's Name__ ____ ____ __ -- - ----------- ------- --- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ 'M t I / ❑ Other ❑ Number of living units: _ _.___' umber of bedrooms _-7- Number of baths __1___ Lot size 'Water Supplyi Public.system Community system '❑ Private [] Depth to Water Table ________ ft. Character of soil to a depth of 3 feet Sand Gravei E] Sandy Loam Clay Loam E] Clay El Adobe Hardpan ❑ Previous Application Made: Yes El No New Construction: Yes RNo ❑ Y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f public se er is available within 200 f/ee+. Septic nk: Distance from riearest wel �istancq from Ifou ation__— Ma er' I ------4----- No. of compartments------- -----7L!_------- ize_ __x -----Liquid depth.... T �. ----------Capacity--C.} ------- � Dispos Field: Distance from nearest wel -�istance from foundation__z/___, _-Distance to nearest lot li � Number of lines__________ ' _ --_____ Length of each line_-__-__-_______�- Width of trench_____�_ --- ------------- TypeDf1 of filter materi __ �� j -_epth of filter material------ --------Total length---------(-- ---- ------_eepage Pit: Distance to nearest well----------------------Distance from foundation______-___________.Distance to nearest lot line__--___________- ❑ Number of pits-----------------------Lining material------------------ ----Size.: Diameter__----------------- - - ' - - Depth--------------------------------- Cesspool: Distance from nearest well____________°___Distance from foundation--------------------Lining material----------------------------.___ El Size: Diameter•-------------------------------------Depth---------------------------- --------------- Liquid Capacity -------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building t ❑ Distance #o nearest lot line_________________ J --------------------------------------- t Remodeling and/or repairing (describe)_____________________ -------------------------- 1 f --------------------------------------------------------_------- 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 laws, and rules and regulations of the San Joaquin Local Health District. (Signed__--- - - = — f'--------- --- --``_'. ---------------------------------- -----(Owner and/or Contractor) Y•---•----------------------------- ------------------------------------------ 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 B _____ DATE—_.----_ REVIEWED BY -------------------------------------------- -------- - ------ DATE__ BUILDING PERMIT ISSUED------------- ----- ---------------------------------- - -------------------------------- DATE -" Alterations and/or recommendations___ -----------__ ------------------------------------------ - ---------------------------------- ------ ----------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------!----------------------------------------------------------------------------------------- --------------------------------------------------- -- ---- --------------------------------- -- -----------------------•---------------------------=---- ----------------- I ------------ -- -- ----------------------------- -- FINAL INSPECTION BY-------------1 --,- � 3 - 3Z -. -1 --------------------------------------•--- Date--------- ------------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North C" Stockton, California " Stroet I Lodi, California Manteca, California Tracy, California E5-9-2M 8-51 Revised W-2100