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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 11/ / Date Issued ---------'- (-5 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. JOB ADDRESS AND LOCAT�'OWN---------------e_;u-------)`—1----- ----- -----------------------------------...--------------------------------- Owner's Name---- --------------_rfl' -•-------------------- --- - - ------------------------ ---------.- Phone2/04��-4-7-- Address...• --- Contractor's Name------------------- 1, �, Phone ------------------------------ --------------- Installation will serve: Residence [''Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/--- Number of bedrooms _ Number of baths .-/- Lot size ------146_.yr�_ S Water Supply: Public system ❑ Community system ❑ Private @R"5-epth to Water Table•_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ( Iardpan ❑ 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.) tic Distance from nearest well-----------------Distance from foundation--------------------Material ______...__.______-_____._._..________--_._____. No. of compartments ------Size------•--------•----------------Liquid depth---------- ------Capacity----------------------- p eld: Distance from nearest well---.-------------Distance from foundation----------------__ Distance to nearest lot line-__________..__. Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material_________________________Depth of filter material_-_._.___..___-_-____.Total length------------------------------------------ I r I Seepage Pit: Distance to nearest well_____�S__--------Distance from foundation___-/0_.__-_-.Distance to nearest lot line__ _ %1 [� Number of pits....___-----------Lining material-_ --Size: Diameter._... __`_--.--Depth------ A-s-4•�---.-------•-- " Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material---------- -._- - ❑ Size: Diameter--------------------------------------Depth----------••-------------------- - ----------------Liquid Capacity------------------ --------gals. Privy: Distance from nearest well____________ ________________________________Distance from nearest building----------------------.------------------- Y ❑ Distance to nearest lot line Remodeling and/or repairing (describe):------- ----------------------------- ---------------------------------------•-- -------------------•-------•---------------------------•--•---------------------------------------- --•-------------------------------------------------- --------------••------•-- --------- -- ------------•---------•-••------- ----------------------•-•---------••-..---------------------•---------------------------------•---•-------------------•---•-------------- --------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------- y ---- +t----------------- --- ------------------------------------ __��____ Owner and/or Contractor) By:----------------------------------------- !- Title ----- ( } --F----•----------------- (Plot - plan, showing size of lot, location of system in relation 9 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--------------- -- - ----------- --- --••---•--------------••----------------------------------•- ____________________________________________________________ _ ________________ _______ _____ r _________ -----------------------------._-----------------._ ---_____________ ________..._____.____._____-_-._.__-____.__.________-_--______.__._____-_-.__________.____..____.____..____ i FINAL INSPECTION BY:..---- ------------------------------------ Date-----. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Es-9 145446 ATw000