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.L� APPLICATION FOR SANITATION PERMIT Permit No..✓� •- I (Complete in Duplicate) Date Issued Applica+ion is hereby rnade'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------ � '-------- Address ------------ te---------- t-a•�----- -._--%lte Contractor's Name____� f� -----�----- '�--___ _-------------------------------•----------- Phone----- Installation will serve: !Residence Apartment House E]Commercial ElTrailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms --?-. Number of baths J---- Lot size ------ --- --- --------•- ---------------------------------- ater Supply: Public :system ❑ Community system .(Z Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [X Hardpan ❑ Previous Application Made: Yes:❑ No [2q New Construction: Yes DO No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.). 1 Septic Tank: 1s 6nce from nearest well _________________Distance from foundation__________--____ ❑ _ Material ------i ------ o. o�` ompartrnents------------------------ Size -------••----------------------- ------------ -------------------- 0C//Liquid depth---------- --------------- Capacity ----------------------- Disposal Field: Distance from nearest well________________ ,Distance from foundation -------------------- Distance to nearest lot line ___-________.____ Ember of lines----------------------------------- Length of each line -------------------------: ---Width of trench nch Tyof filter material -________________________Depth of filter material -------------- Total length -----------------------------•---- Seepage Pit: Distance to nearest well -------- f!7 :' -_Distance from foundation______`- _r -__:--.Distance to nearest lot line Number of pits -1 -------- material --_C_------ - - 3'` f it g ��Qize: Diameter ----•- Deptn' �} Cesspool: Distance from nearest well ----------------- Distance from foundation__________________ _Lining material___.____.__-____--.___ El rr� Size: Diameter_ ._ Depth --------------- ----------------- --Li Liquid Capacity - � I; q p Y- ------------------ -------gals. Privy: Distance from nearest well _--------___ Distance from nearest building - --- ❑ Distance to nearest lot line------------- _-- ------------------------------------------------------------------ Remodeling and/or repairing (describe)_________________-----_---_-- ----------------• --- ----- •- ----------------- t-------•-- ---------------------------------------------- ----•-•-------••------._------------------------------------- I jhereby certify that 1 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)- .R s ,, l ------- ------(Owner and/or Con+r'actor) By: ..... IX --- L ` - ----------------- Title --- (Plot plan, showing size of lot, location of system in relation to wells buifdln ( ) -----`----------------------- gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y. -%%'_- - Y._ + ._°-'------ REVIEWED BY i'`' - DATE_ ---- ----------------------------------------------------------•-------------------- DATE---r--V BUILDING PERMIT ISSUED-------------------------------------------------- ---------------------------7- ------ DATE------- -- Al+erations and/or recommendations:--------------------------- - .<-�--------------- ----------- ----------------- ------------------------------ - - ------------------------------ ---------------------------------------- FINAL INSPECTION --------- ------ ------- Date ------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California i 8f4 North "C" Street Lodi, California Manteca, California Tracy, California ES -9-2M � IRevised W-2100