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APPLICATION FOR SANITATION PERMIT Permit (Complefe in Duplicetel a4 � Date issued ...... /- Applica4-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.,, JOB ADDRESS AND LOCATION }.--- ✓- ......%._ +!.- = _ ......................................................... Owner's Name.-. .......... ---•---------- -- -----------------••-•-•------•-- - ................. ------- r ....................... Phone .............. - Address r --------- --- -------------------- ------------------------------------------ Contractor's Name. /'_..c�'!v.--� -yf.* !-•-- r _----------------:..""""Phone �07 �= •� �- r Installation will serve: Residence ❑Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ Number of living units: --.... Number of bedrooms: Number of baths /..... Lot size _.td.. k ---- A..Ar>.._••••••_ L Water Supply: Publics stem `• pp y: y ['��•-�Gommunity system ❑ Private ❑ Depth to Water Table .��_.._ ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9_ -=Hardpan ❑ Previous Application Made: Yes ❑ No [,New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �p Septic Tank: Distance from nearest well %.Q_ ____-Materiai_.__�.- !' �-•r_-_---•_ p f„Yftli4__ Distance from foundation____._. f v�-'- No. of compartments.-.. �-- --_. 4---A--�-t7.•Liquid depth. --- �_.�.- ...Capac,ty--- o� Disposal Field: Distance from nearest well.�"•�.._ Distance from foundation --- 1._Ur._------- Distanco to nearest lot line .... l)......... Number of lines ........ !_.. .......... Length of each kne.... L5_` d.......(__...Width of trench_._.. � ...................... - �a .Q Type of filter material/_�,Z,_..___...._ Depth of filter mater:aL...%�-.____...Total length___t�?..................._._____.._..-. i Seepage Pit: Distance to nearest welloi''+""�........Distance rom founclation_..At�..._. Distance to nearest lot line-- �._.... b-�'"' Number of pits....../ .. Lining material:�...Size: Diameter ........... . Depth.. . --- --- ------- Cesspool: Distance from nearest well ----------------- Distance from foundation . ............Lining material ....__--------------- ❑ Size: Diameter --------------------------------------Depth-.............. ---------------- -------------.--Liquid Capacity--------------------------gals.3 Privy: Distance from nearest well ..... _____---------------- _---------------------- Distance from nearest building ...................... ................... �. ❑ Distance to nearest lot line ................ -------------- -.................. ....................... ..-------- .................................................. Remodelingand/or repairing (describe):.......................•----......_.._..--------------"---"------"...---........-"--•---------•----"-----------------------------•--•-••- .._....... . --------------•..................................... `^ ........................ •..............................•--------.........-------•------------------------"--"---•--------...............--............ _......... .......... ---•--••--------------------------•- --.... -•-----------•------------------------------•---••------------------------•----------------------...-- - -a ......--------•_....-- ------------------------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County €` _ ordinances, Srfate•lgws, and ruulles and regulations of the San Joaquin Local Health District. `e le r Si ned _._.._.. - 9 }------_ ...... ------- (Owner�ertd/or Contractor) -.�R-•�--vr ,.+�... ----.(Title)---- B _ (Plot plan, showing sae 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 ---- REVIEWED BY --- ..... .. .............. .% .... �� , . DATE-------- y BUILDING PERMIT ISSUED----------------------------•-_-•- -----._---- DATE_._.. --...---- . . _ Alterations and/or recommendations:____.... --------------................... - FINAL INSPECTION BY - ._ . ........ Date----- ------------l-- . �. `.V1-------- ..... ... .... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North 1•C• Street Stockton, California Lodi, California Manteca, California Tracy, California ES r1M 14S.I ATK'OJU 12-54 � (`