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f I tS y APPLICATION FOR SANITATION PERMIT Permit No, . (Complete in Duplicate] Date Issued work k Application is hereby made to the'San Joaquin Local Health District for a permit to construct and install the k herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION ---------7 ----- � Owner s Name--------------------- --_------ s- •--------------- -A.. -------------- Phone------------------------•------ Address----------------------------------------- -------------------- ------ - ----=------ -----------•------------•--------------- A --------------- Phone-------•--------------------------- Contractors Name------------------------------------ ---------- - ---- --'----------- - - Installation will serve: Residence's -Apartment House []_ ..Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of baths _-_-_f__ Lot size ______--6-0-V--=---- ----------- ----- Number of living units: ___I__ Number of bedrooms Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft, Character of soil to a depth of 3 feet: Sand E] Gravel ElSaad, oam ❑ Clay Loam xClay E] Adobe E] Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes,,Rt—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_________________Distance from foundation___________----___.Materia4_____-____ ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------------------- ---Capacity Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance.to nearest lot line_______---_______ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- W Type of filter material--------------------------Depth of filter material------------;----------Total length--_--------------------------------------- a Seepage Pit: Distance to nearest well----------------------Distance-from foundation--------------------Distance to nearest lot line____--________-_ ❑ Number of pits-_':-----------------Lining material-----r---------------- Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well_ 1t_Distance from foundation.--/—*----.Lining material-__ �{ Size: Diameter--- k (A, - 5------Depth-----------�-----------------------------------Liquid Capacity i gals. rt. Privy: Distance from nearest well------------------------------------ Distance ------Distance from nearest building--:--------------------------------------- ❑ to nearest of line----------------------------------------- --------------------------------------------------------------------------------------------- r - - Remodeling and/or repairing (describe)------------------------------ --------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- --------------------------- -------------- •-----------------------------------------------------------=-------------------- I hereby certify +hat I have prepared this application and that the work will be dope in accordance with San Joaquin Count""'''` ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed} -- lof�s7ystem. lieiation -- ------------------------------(Owner and/or Contractor) ----•-----=- -------------- ----------------------------------------(Ti+ -------------- sr• ;(Plot plan, showing size of lot, locatio to wells, buildings, etc., can be placed on reverse side}. 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------•------------------- DATE = --- { REVIEWED BY---------------- -----m -- -------------------- DATE I BUILDING PERMIT ISSUED------------------------------ - DATE Alterations and/or recommendations: f -- -- ------------------------- •• -- --------------------------------------------•---------------__----------•---- ----------------------------- ---------------------------- - --- -I.1-19P------ ---------------------------------------- ------•---------------------------- ------------------------------------------ -- ---------•------------------------- ---------------------------------------------- ------ -- - --- ------ -� ----------- --------------------------- - _ � FINAL INSPECTION BY: !U Date- --------- /l f ------------ - ------ ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT , 130 South American Street 30o West Oak Street 132 Sycamore Street r e14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8.51 Revised W-2100