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APPLICATION FOR SANITATION PERMIT Permit No. ----- -[.:_. : ' 1 (Complete in Duplicate) 3� 1 Date Issued ....oo, 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 ,tO-3 ------ ------- Owner's Name' _�__ Phone ,Q 3--- Address__I.....aq-----t-J ----------------------------------------------------- .` ----- - -- - - • - Contractor's Name_____ 4. --------------------------------------------• ---------------...--- -----------•---------------------------------- PhoneA_4----2=_-a4 4-•-1-- Installation will serve: Residence [?/Apartmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -___!__ Number of bedrooms _-Z-_ Number of baths -----[_ Lot size ..___1_2r_�'_____________________ Water Supply: Public system 5?" 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[f Hardpan ❑` Previous Application Made: Yes ❑ No New Construction: Yes VNo ❑ a TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.). y Septic Tank: Distance from nearest well____ __________Distance from foundation---------:----------Material------------------------------------------------- ... No. of compartments--- - _ :_- Size-------- -----------------------Liquid depth__._--------------------Capacity.----- ispos�: Distance from nearest well-"'° ' :___Distance from foundation----------______--.Distance to nearest lot line----------------- q Number of lines------ --- -- - --------- .. -------Length of each line--------------------- of trench---------------------------------- e Type of filter material Depth of filter material-----------------------Total length---------------.___.---------------------- See pa Pit: Distance to nearestwe -----------�--Distance from foundation__--/: life....___.Distance to nearest loft e--_� Number of pits-------- ------..Lining mate rial_....Size: Diameter__..-..............Depth.... �`--_ ____ .... j 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---------------------------.-------__--__. I ❑ Distance to nearest lot line.,.------------- -------------------- ------------------------------------•---------------------------------------------------_------------ Remodeling and/or repairing (describe):----- ---- ------�_¢'-` -- - ------ ------ ----- ------•--...--- ----�-----------_-•----------------- -------....----------- ----------------- -----------------------------------------------------------------------------------------•----------------•------------••---------------------------•----•------------------------- --- - I -----------------------------------------------------------------------------------•------------------- I I hereby certEfy that I have prepared this application and +hat +he 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) - •-_ An ---------- ---------------------------------------------------------------:--- -----------------------------------------(Owner and/or Contractor) By�---•------ t (Title) ►4-+ c l (Plot plan, showing siz 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_ ---- ------------------------ BUILDING PERMIT ISSUED -------- ---- ------ DATE-------tn--------------- ------ Alterations and/or recommendations---------------- - - --------------------- ---------------•------•--------------------------------••-- .---------•------••---' - ---------------------- -------•-•------------------•--•---------•----------------------------- ------- ---------------------------------------------•--••-------------------------------------------...--------------------------------------- -------------------------------------------------------- ------------------I------------------------ -- --------•----------- --------------------------_ ---------•-•------------ ------------------- ------------- -----•--------------------------•-------------------- FINAL INSPECTION BY----------- -------�-- ----r-_ �'° ° -�- "►�' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street t Stockton, California Lodi, California Manteca, California a Tracy, California E5-9-2M 1455a6 n7WOOD ,2-s4 y - 4r