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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Y! I Date issued --- _---.--1-._~_--- Applica-lion 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--- - S� � 4�-i ---.5 `` h - ---- --------------- ----------------------------------------•--------------------- Owner's Name--------!c_a--- 3` - ..-- .r -WY ---------------------------------------- - ------------------------------------- Phone----•----------.- - -------••-•--- Address------fD--'s-- ---------•--•- r Contractor's Name------- -•---------- --------r----------------------------------------------------------------------•--------- Phone-------•--- E Installation will serve: Residence ❑ Apartment Mouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._,--.. Number of bedrooms _- — Number of baths .--J--_ Lot size Water Supply: Public system 9, Community system E] 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`W New Construction: Yes-"J 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-----------------Distance from foundation-------------------Material-_--_--____--_-.----_..-----__-----.-._----____-. -S�^ No. of compartments---------------- ----------Size-----•-•------------------------Liquid depth--------------- .------Capacity----------------------- Disposal ----- --- ------------ Disposal Field: Distance from nearest well-_..............Distance from foundation--------------------Distance to nearest lot line----------.------ �'�' � r Number of lines-----------------------------------Length of each line-------------..------------.--.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------j----„-,.- Seepage Pit: Distance to nearest well-.l ?xr....---Distance from foundation--I_C►-----------.Distance to nearest lot IjnP...!4-----_--_ Number of pits..----I-------- --Lining material!e-±-)L(l\X`5ize: Diameter--..,/__..-------._-Depth-____&---------------------- 4 Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material--------------_----._--._.---------- �J ❑ Size: Diameter--------------------------- - -------Depth--------------------- ----- --------------------Liquid Capacity----------------- gals. Privy: Distance from nearest well-----______--------------------------------------Distance from nearest building------------- ---------------------- El Distance to nearest lot line----------------------------- Remodeling and/or repairing s (describe:_-__---.. _-_moo'___ J\� a 'r °��--- -- � ----- -�.. � ties ----------------------------------------- -------------------------------------------------------...------------------------------------------------------------------- ------------------------------ ----------------------------------•-----------------------------------------------------------------...----------••------------------------------------ --------------------•----------- ---------------------------------------------------------------------------••--------------------------------------------•-------------------.-...----------------------------------------•-----------•---------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta law , and rules and regulations of the San Joaquin Local Health District. {Signed}...'.. . -_.----.. ,_ ---------------(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--------�------------------------------------------- REVIEWED BY - --- ----- DATE -------------- --------------------------------------- BUILDINGPERMIT ISSUED------------- - ------------ ------------------------------------------------------------------ DATE-------------------•-- Alterations and/or recommendations:--------- ---- --- - -------------------------------------•-------------------•------------------ f - --------------- --------- ------------------ ----------------------------------------------------------------------------------e------__---------- -�----- -- -------140--11 11 --------------------------------------------------------------------------- -------- ---------------------------------------- FINAL INSPECTION BY-_;L �{�� ------- ------ -----------------••---- Date------ �CJ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATWOOO ;2-54