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APPLICATION FOR SANITATION PERMIT Permit No. ... IqAA (Complete in Duplicate) / Data Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor herein d scribed. This application is made in compliance with County Ordinance No. 549. x „. f.�, cac1 1 JOB ADDRESS AN '1OC TI .. _ __ __ ___ _ -- - u-c:�.t- "` Owner's Name----- •11 L•' ._ �'— Phone q Address-----•------------------�--f---=---6 -'--- '----��--�-----------------------------------------------------------------------• •------ •------••----•------- -------------------------- Contractor's Name-----=--------------- -: - ---------------------------------------------------------- Phone-------- O -- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Xs.66� Number of living units: _ _- Number of bedrooms ___-Number of baths ._-_---- Lot size .----------Jr_- __-zL ./..5-Q_ _________________ Water Supply: Public system ❑ Community system ❑ Private tq Depth to Water Table i�& ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe , Hardpan ❑ Previous Application Made: Yes ❑ No�Z New Construction: Yes X No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: f r (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) _ , - Septic Tank: Distance from nearest well__e�.�____ Distance from foundation_ _0___________.Material___ ___ ____ __ �_______________ No. of compartments--Z.---- - -- _-Size__5_G'_ Liquid depth_-6__J`"__-_ ------- Capacity.P.Cja00.j!___ __ Disposal Field: Distance from nearest wek_7Q.._..._Distance from foundation__j__Z_........Distance to nearest lot line_____ 1" Number of lines-_+it._ _-----__ ______Length.of each line_ ' Q�__-Width of trench.. ---------- -- - ------------------------ Type of filter material_0_� _ ____Depth of filter material...I --______._Total length__ Seepage Pit: Distance to nearest well_1©_Q__'_........Distance �fr�fn 'fro ndation---1_A,.'_..___.Distance to nearest lot line_____ 0� INumber of pits----I----------------Lining material6 _..Size: Diameter-C3_5_".____Depth.... ----------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter---- ---------------------------------Depth----------------------------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well----------------------------------------'-------Distance from neares# building-------_-_----------__------___- i ❑ Distance to nearest lot line-------- -------------------------------------------------------------- --------------------------------------------------------------------- : Remodeling and/or repairing (describe):-,------------------------------------------- --------------------------------------------------------------------------------------.............. --------------------------------------•--------------------•----- ---------•-----------------------------•----•---------------------------------------------------------- ------------------------------------------•----------------------------•--•--------------------------------•-----•--•----------•-----•---------------------------•----• ------------------------------------------------------ ------------------------�---------- ----------------------`-------------------•--------------------------------------------------------•------••--------------------------------- --------_-------------------------------- I hereb cert` � y that l have prepay pplicati nd that the work will be done in accordance with San Joaquin County ordinances, ate aws, and rules and regula_figris of A S n Joaqu n Local Health District. (Signed)--------- ---- -- ---- -&--4----- --- -- --- --- --- -- -----+--- •------------------------------- m_.�ontractor) B ---- -- - - -- - ----- ---- - - -------- ----- (Title) 1a (Piot plan, showing size of lot, location of system in relation to w I , buildings, e�tcan be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY L ----------------------------------------------- DATE------ -------- REVIEWEDBY-------------------------------------------- -------------------------------------------------------------------------------- DATE-----------•--------------- ON BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------> Alterations and/or recommendations:-------- ---------------------------------------111---------------------------------------- --------------------•=------------------------------ ----------------------------- -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ ----------------•-••----------------------------------•---------------------------------------------•----••---- -------------------------------------------------------------------------------------------- --- -•---------------------------------------------------------------------- --------------------------------------------------- ------------------------------ -----------•---------------------------------------------------------------------------------------------------- ------------------------------------------------ ------------------------ FINAL INSPECTION BY:------------------------------- �------:�;, ---- Date------------------ ......... 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 ES---9-2M Revised W-2100