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APPLICATION FOR SANITATION'PERMIT Permit No �!L - (Complete in Duplicated / � � 1 bate Issued;__Q,S,��_5 / Application 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-_---X3",3,3_ F, �• . Owner's Name----------- C .. -------------- --------------------------------- Phone- Address S • Contractor's Name______________ e2 ------------------------------------------------- ------ _ �---_��,.�„��.��- -------------------------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial 1 ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-_____ umber of bedrooms __.?Number of baths ___q:___ Lot size Water Supply: ,Public system Community system ❑ Private ❑ rDepth 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 VIN, ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` i{ (No septic tank or cesspool permitted -if public sewer is available within 200 feet.) LN Septic k: Distance fromanearest well------------------- from foundation--. 010 No. of compartments---------�----------Size----- ,. s ' Liquid depth �i1---------Capacity---•-crC Disposal_Field: Distance from nearest well------- ------.Distance from foundation__ __� _ _--_-Distance to nearest lot line____c _.. Number of lines----------- ------------- Length of each line_'------60--------------Width of trench---------2- �/ \�y -------------------- Type of filter material___/ ____ Depth of filter material �/ - --------Total length-------------1p--�------ ----------------- - eepage Pit: Distance to nearest well _-_--------Distance from foundation__lv________ _____ _..Distance to nearest lot line___________-____ ❑ Number of pits-------- ------- -Lining material-------- ------ Size: Diameter------- --- Depth------- ------ ,. Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material--_______-----______ ❑ Size: Diameter =-------------------------------Depth-------------------- -----------------------------Liquid Capacity---------------------- Priv ------ al-- - g Y: Distance from near6sf well___________________ ________Distance from nearest building ❑ Distance to nearest lot line____________________ _ ---------------- Remoclelingfand/or repairing ------- - Lf-Q Mi---------------------- -------------------------------•------------------------ ------------------------ -------------•----------------------------- --------------------------------------------------------------------- ---------------------------------------- I hereby certify that I 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. V. (Signed)_. __I�_l_ _-- - - r -' _______::___(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 REVIEWED BY DA APPLICATION ACCEPTED BY -- ---------- ------ ------------------- DATE------- f �� DATE----------------------------- BUILQlNG PERMIT ISSUED----------------- ----------- -�---------------------------------------------------------- ---------------...--------- • - - -- -- DATE - - t rations and/or re rrtmendations----- -------- - /------�- f ,r- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --__---- ----- ------------------------------------- - ------------------- FINAL INSPECTION BY----------- -- ------------- _ I ------ Date---- --- SAN -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 9-51 Revised W-2100