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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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. 17Z� 3Z a s s~ Dar JOB ADDRESS ESS AND OC OCATION... --�'L`'�'•�.-.-��---------- ------- ��.�-..--------- -'z Owner's Name- -`r�„` ----- ----------- Phone------------------------------------ '. Address -_' 7f. '------------------------------------------------------------------------•------..._ ----•- -------- Contractor's Name -- fes. --- --- ----------- ------ ------------------------------- Phone. Installation will serve: Residence W_ 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 .6'n-..dit. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No q--New Construction: Yes,k No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: ' tante from nearest well-----------------Distance from foundation--------------------Material.......-___._......----------.-.------------- .-. ❑ ��of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity--------------��--- Disposal Field: Distance from nearest well-.. Distance from foundation.. Distance to nearest lot line.--<- ...--._.__. p / �r ,, Number of lines--- ............ �.____.. ength of each line--------'jam..._..,-,.Width of french-----_�--A�___----------- Type of filter material---lA_..------ th of filter material...... --..Total length-.--..._.. -------------------- I Seepage Pit: Distance to nearest well.. Distance fr fou daiti n—'20.......Distance tp,nearest lot line---/� ...._ � Number of pits.../___.....-. --Lining materia( rn -.i > Diameter._.... _ ---Depth----- -------------- rop, 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..-..........--.----.-..-..-..___--...... ❑ Distance to nearest lot lire--- ------------------------------------------ ---------------------------------------------------------------------------------- ------------ tj Remodelingand/or repairing (describe)---------- ------------------------------------------------•-----------•-------------•-•----------------------------------------------------------...... ------------ ---------•------------------•------------------------------------------------•-------- ------•-------•----•---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State s and rules and regulations of the San Joaquin Local Health District. (Signed) - --- `J - - ---- ---- ------------------------------------------------- -------(Owner and/or Contractor) -----------------(Title)------ ------------------------------------- (Plot plann, 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--------------- ---------------- REVIEWEDBY--------------------------------------- .. --------- ----- ---._. DATE---------- ---------------------------- -------------- BUILDING PERMIT ISSUED..-....._._...-._ DATE...----.!_ -......_. Alterations and/or recommendations:- - ----- -------------^------------------------ --------------------------------- -----••------- ---- ---------•-------------------------------------------------------- --------•----- ------- ------------------- --------------------------- ------------------------------------------ -- -----------------------------------•---------------------------------------------- - FINAL INSPECTION BY:.. ------------ -------- ------------ Date - - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Sfreet Stockton, California Lodi, California Manteca, California Tracy, California E5-9 1454"ATWOOD