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APPLICATION FOR SANITATION PERMIT Permit No. ____ ___ - i/ (Complete in Duplicate) y.......... RDate Issued --- ----- - - Applica+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. JOBADDRESS AN LOCATION ; --- - ---------------------- ..----------------~---------I---------------------------------- I Owner's Name ----- -----------' Phone-.-------------------- = ? .t Address----- .... -------------- -----------------•------------------------------------------. -------------------------.-•----------�------•-------•---------------- -. I -------------------- ------ Phon - --r�' Contractor's Name------ -•---- Installation will serve: Residence Z-AT,-rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __J____ Number of bedrooms __)Number of baths rte----- Lot size ---' �___ _._ -13-ja__.___.__._ Water Supply: Public system �mity system ❑ !.Private ❑ Depth to Water Table 3-0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�•-span ❑ 7 Previous Application Made: Yes ❑-No 'ew Construction: Yes [❑ No.[J'"— i TYPE OF INSTALLATION AND SPECIFICATIONS: " I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well ___ _________Distance from foundation_4-_to_-_P...Mate{ial__ ____________ __._________ -_------..__. No. of compartments-- ----: Size_-- ---?S_- :-..Liquid depth_ -./ --------..Capacity___ --- ----- Disposal Field: Distance from nearest weli_E .-Distance from foundation___Z.4__�..-.Distance to nearest lot line___ws__a..... Number of lines!-------'/-------- Length of each line-----. Q_�`._---yr--.Width of trench__-_--`------------------ Type of filter material.... _________Depth of filter material.....-�.__._.___Total length____,_?__Q_________-____.--__._.,__.__ � Seepage Pit: Distance to nearest well rY' - _____Di0ance m fo ndation___...____�_/.Distance to nearest lot line--- Seepage bV - Number of pits_-_-I______________Lining material__,...Size:'Diameter_-Jl?_L�:_.__Dep#h__.�-�-----_______._._____. r Cesspool:_ _ Distance fiom_-_nea.restwell___________..__--Ditance.;fromrfoandat.�on� .____.__-. _.Lining materiah_-.--- t�_w = ❑ Size: Diameter--------------------- ------------ --Depth------ ------- ----------- ------------Liquid Capacity---------------------------gals. Privy- Distance from nearest well' _~_ - __---_� ?---------------------------Distance from nearest building____.__-____._____________----___.__.__. ' ❑ Distance to nearest lot line---------------------)-------•--------------r- --------==---------...--•---------------------------------------------------------------------- Remodelingand/or repairing (describe)=-- ------------------------ =---------------------------------------------------------------1--•----•-----------------------------------•--------•--- a 1l -------••--------•-•------------------- -----------•-•--------..------ ---------- I hereby certify th'at'1 have prepared this application and that the work will be done in accordance with San Joaquin Count q Y ordinances, State 1 ws, and rules and regulations of the San Joaquin Local Health District. (Signed) 'h ----------------------------------------------- - 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 1 APPLICATION ACCEPTED BY-------- --------------------- ---- ----- = --- ------------------------------------------ - DATE--------- ., - REVIEWEDBY-------------------- ---------------- -------=------- _----------------------- DATE BUILDING PERMIT ISSUED-------•----•---------------•----------------------' - ---- ---------------- ------ DATE--------------•----------------------------------------•----- �. Alterations and/or raEomrnendations:_----- --- -------------------------'----- ---------------------------:------- ------------------------------------------------- ------------- ----_---•------------ ------------------------------------------ --------------•- - --------- --- - '`� i� ------ -----• - ------- --------- 11- -------•-- r 'vR - ---- ----- - ------------------------------------------------------ -------------------------------- ------- u -------------------------------------------------------------------------------------------- i�------------ ------ - rl Date.-- .— ---`-----°��------------ ------ FINAL INSPECTION BY:-------- -� ��- --------------------------------- ------------------------- a 1 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 11 �. EE-9-'22 145446 A- . 1Z-54 f�