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i APPLICATION FOR SANITATION PERMIT Permit No. ...... (Complete in Duplicate) Date Issued ____!___ 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. X37 � JOB ADDRESS AND LOCATION-- . a / d�LS�{!-]- __- _.. .1--"------ - mal. -�►- �--•-- -- - - - Owner's Name-_ "n � --------•--------------- ---------------- ---- ` Address---------------- --------------------------•--.......---_---_----- ---....---------...-------------•-•----------•-------- ---------------------------......-------------------------------------------------- Contractor's Name---- -------- ` ---•----•---------•--- Phone---------------------------------- Installation will serve: 'Residence Apartment"House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: umber;o bedrooms -- Number of baths ---/--- Lot size.------- �___________ ___ ~ -4. . Water Supply: Public system Cornmunity system [I Private ❑ Depth to Water Table --J-_--__ f Character of soil to a depth of,3'Teet: Sand F1 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [❑ Hardpan ❑ Previous Application Made: �y es ❑ No New Construction: Yes Vo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I ' (No septic fank'or cesspool permitted if public sewer is available within 200 feet.) , Septic Tank" Distance from nearest well------ Distance from foundation_--I0_-------_.Mater l_��________________.._-.____p_..__..____... ` No. of compartments4_-----_y.__---------Size__3_x� -------.Liquid depth-------46-` -----..Capaeity_- -`��----- -pis.o s 1 Field: Distance from nearest we!€_._-___._-____Distance from foundation---w___.____.Distance to nearest lot line______'r----- Number of lines-_____-:_ �.____ .____ _'_Length of'each line___-_-___GQ�jf.e7_____-Width of trench--------- Type of filter materia LDepth of filter material____.__ length________________l _______ ------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------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 gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building._---...____.___-_---_------.---.--. ❑ Distance to nearest lot line------------- ----------- --------=---------- ------•--------------- --------------------------------------------------------------------- Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- ! -----------------_-_- ---------•----. -•-----•-•-- ----•------•-•----------------------------••-•------------•------------------------------------------•---- - . li •----------------------------------------- ----------------•.--------------------------------- ------•-----------•----------------------•------------------------------------ I hereby certify that I have prepared this app'cati and that the work will be done in accordance with San Joaquin County ordinance tate laws, ules and regulations n Joaquin Local Health District. (Signed)-- -- ------- --- - - -- -----------------------------------------------------------------------------(Owner and/or Contractor) B -- -----•---------------------------------- -------------------------------------�------------------------------ ---------(Title)--------------r-------------------------------------------------- (Plot plan, sh wi g size of lot, location of system in relation to wells, buildings, etc., can:be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-i------- -- ------------------------------------------------=------ DATE----------- -U -- - REVIEWED BY--------------------- ----------------------------------------------------------- -_ DATE------------.1--- --------�---------------- - -- - BUILDING PERMIT ISSUED----_------------- DATE------------------------- Alterations and/or recommendations--------- c ----------- -- y-- - . '�"'� `�''/�' ----------------------•---•--•• ------------------------•---•----------__--_------------ rte �� Date f� ---- 3 �--- -- FINAL INSPECTION BY;-----/----- ----- �'�`------------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lotti, California Manteca,'California Tracy, California r ES-9----2M 10-52 Revised W-2100