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APPLICATION FOR SANITATION PERMIT Permit No. __'�_�Gf�•--_ �. [Complete in Duplicate] 3 _ Date Issued 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 LOCATION... .--- ✓F.w�-( ----------- --------------•-------------------------------------------------------------------------------------- Owner's Name...... = _ Phone------- 8 -------- -- ------------------••-----------------------------------------------•- Address__. r. e ,_. `� Contractor's Nama__, .............. •------•------•----_-_-- ------------------------------------------------------ --------------- Phone---- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths .------- Lot size Water.Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ 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.) Septic Tank: Distance from nearest well____"__71___Distancp from foundation-----/R_'._._.Material--- _ ® No. of compartments______' -----�.-----Size__-6------------------Liquid depth-----%T--------- Capacity_32-_0--- ----- Disposal Field: Distance from nearest weft-_e-------Distance from foundation---/4.---_---Distance to nearest lot line__ Number of lines-------I__ ____ Length of each line_____l479--_____.____----Width of trench---- ''---_-__----. Type of filter material_ _ - ___ _____________Depth of filter material----JF----------Total length_____Stl -------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot Ime-____-_---_____._ ❑ Number of pits----------------------Lining material-----------------Y .._Size: Diameter_--------=------------Depth------------------------------ i cesspool: Distance from nearest wel! _Distance from foundation.----------------- .Lining material____.__________--._.______ ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy. Distance from nearest well _--___-_---------------------------------------Distance from nearest buildingf ❑ Distance to nearest lot line___ ---__.__-_-_---_- ------------------------------ Remod ng and/or re airin rilje :_ - .___._------------------ (des - -- ----- ... ------------•------------ - --------------•------ -------------- ------------------- ------------------------------------------- -------------------------------------------------------------------------------- p I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Caunty ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_-, "& -------- t �+� ---------------------------------------------------------------(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 " v��`, ----------------------- --------- -------------------- lEWED BY ----------------- ---- ------------------------------------------------------------------------ DATE BUILDING PERMIT ISSUED----------------- DATE- ------------------------------ -- ---------- ------------------------------------------------------- ----------- - - Alterations and/or recommendations: , .�_ - l-1_ /// jd� -yr �; ----------- -- --- ------------------------------------------ .........�—�- ' ____________________________________ -------- ____________________________________________________ -----------_____----- Lc.__ FINAL INSPECTION BY:---------------------------------------------------------------- Daite----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100