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APPLICATION FOR SANITATION PERMIT Permit N"61-(Z------- 1 �3 (Complete in Duplicate) Date Issued . - -- Applicaa-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. I J4OB ADDRESS AND LOCATIO t�� __ _' ...---'f- ---- Owner's Name------------= ................ -- --------------- ---------- - -- Phone .1 t Address--------------------------------••-•------------------------ -----------------------------------------------------------------------------•------••---._....._..----•------------.....------------------------- Contractor's Name.. -------------- Phone ---- --------I------------ Installation will serve: :Residence Nj.wy6?partment House ❑' Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1------ Number of bedrooms 4Number of baths ---/--- Lot size ----- 4-1"---- --1-------------- Water Supply: Public'system ommunity -system ❑ Private ❑ Depth to Wafer Table ________ ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [4 "lay ❑ Adobe❑ Hardpan ❑ {� Previous Application Made: Yes ❑ No New Construction: Yes 4"410 LJ v TYPE OF,INSTALLATION AND SPECIFICATIONS-. (No septic tank or cesspool permitted if p 6lic sewer is available within 200 feet.) Septic Tank: Distance from nearest>well__X�—(gPistan e if r:d n-�__ _ ._.Material-____ ______ _ ____ _______- ni q p No. of compartments_:_______��fJ _.__Size____._.______.__ ____ Li uid d th ____ ___..______-Ca acity___ __ Disposal Field: Distance from nearest w li__�_vhlf .[Jisfance from foundation____` istance to nearest lot line._ M' Number of lines______________ Length of each line________7_ i_ kith of trench__________ -__ -----_________- Type or Cter material___ __R :Depth of filter material____ ____________Total length___.--____ r_..___- Seepage Pit: Distance to nearest well-----------------------Distance from foundation________________.--Distance to nearest lot lin ❑ Number of pits------ -------------Lining material-----------------------Size:Diameter-----------------------Depth------:------------------------- —Cess ool:.. Distance from,nearest_well-----------------Distance from foundation______--------------Lining materia)--------------------_- $ize: Diameterw _ . ❑ - Depth-------------------------------- - --- � -- -----.Liquid CapacitY---=--------------------- Privy: ------------- -- --Privy: Distance from rearest well------------------------------------------------- from nearest building____-------------- ____________________-. ❑ Distance to nearest lot line--- ---------- ------------------------------------`--------=-----------•-•--- -------------------------- ---------------------------- Remodeling and/or repairing (describe):----------------------- °-----------------------------•------•-------_....•----------I------•---------------------------------....-- --------------------------------------------------------------------------------------------------•----------------------------------------•-------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will'6e done-in accordance with San Joaquin County ordinances, State IaVP, and rules and regulations of the San Joaquin Local Health District. i (Signed) - -------------- - --- --------------- --------------------------------------------(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 APPLICATION ACCEPTED BY------------------------- --------------------------------------------------- DATE ` REVIEWEDBY------------------------------------------------------------------------------------------------------ ---- • -----. DATE----------------------------------------------- BUILDING --•---------------- -----BUILDING PERMIT ISSUED--------------- -------------------------•-------------------------•-- --------.------•---`=---------- DATE.------------------------------------------------------------ Alterations and/or.recommendations------------------------------------------------------------------------------------------------------------------------ --------------------------------- ------------------------ E - ----------------------------------------• -------------------------------------------------------------------------------------------------------------------------------------------------------..------------------------ i FINAL INSPECTION-BY::-- _ _ ---------------------------------- Date...----- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ;-.- - Revised W-2100