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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Z .Y Date Issued .___� ._"y_``S Application is hereby made to the San Joaquin Local Health District for a permit to constru t and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L CATIO --.._ _ _ _ Owner's Name--P ....... -.. w=C T ---- ------------------------------ Phone___-------��"-•--- Address__�_� ,Ns =_ -- -------------------- A � _____ Contractor's Name-------_--•-- g Installation will serve: ResidenceIO"'Apartment House ❑ Commercial ❑ Trailer Court E] Motel [] Other Number of living units: _I____ Number of bedrooms-�_ Number of baths ___l___ Lot size __ _ - CO--------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table---q__�_Jft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclob4�-Hardpan ❑ Previous Application Made: Yes ❑ No1' New Construction: Yes 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- --- ffoundation __--_ --Distance from i �on__.__� ------.Material-- - - - ------------------- No. of cor^partments__ ------------ ._ .___ _ �__Liquid depth____r_ __ _ -Capacity___ Disposal Field: Distance from nearest well_ �,j_r_._Distance from foundation____----------Distance to nearest to line_____r...__. �' Number-of lines.-------/---------------- -----Length of each line-------� _f'-------_.Width of trench.---- -- ----,--------------- Type of filter materia�AV Zrf _____Depth of filter material___!- g -- - - Total length --.��-------------------- n � Seepage Pit: Distance to nearest well.__ 7-Distance "-u ion to to nearest lot iine__ ________ Number of p:fs------- --------Lining material__ ize: Diameter__-. ___�_____________Depth...__lj 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 line--------------------- - - ------------ --------------------------- Remodeling and/or repairing (describe) 7 �-- 1_ek--/f2--------------------- -------------------------------------------------------- _----•----------•-------------- --------------------------•--•-••-----------------------------•-----------------------------------------------------•---•--•-----•------------------------- ------------------------------••--•------------------------- ---------------------------- ----- -----------------------------------------------------------••-----------------------------•----•-------•------------------••---------------------------•--•----------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, an ules and regulations of the San Joaquin Local Health District. 3 (Signed)... -`P- ------------• ----�------------------------- - --------------- -------------------- -----------------------------------------(Owner and/or�C�ontractor) �- Tif (Plot plan, showincYsize 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__7- ---------------------------------- REVIEWEDBY----------------------------- -- ---------------------------------•------------------------- - ------------- DATE --- BUILDING PERMIT ISSUED--------------------- --------------------------------------------- DATE----------- . �---- Alterations and/or recommendations----------------------------------- -----------------------------•----_-------------------------•-•-------- ------------------------------------------•-----------------------..-------------------------------------------------------------------------------------------------------------.------------------------------------- ---------- -------------------- ----- - FINAL INSPECTION BY:........ �_ �-----------------------------•----- Date---Z.1;4.-4; . --- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streot 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M I4-52 Revised W-2100