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APPLICATION FOR SANITATION PERMIT Permit Na. ._ ______ "...._ fo �1 in Duplicate) (Completepate Issued ._.."1___.-(---------- P—"A— ________,—"A -' LA-1 ' 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. 544. �' JOB ADDRESS AND LOCATION...-_ ^ � '� Phone Owner's Name_______ -� _ -• - ¢ Address l-� Contractor's Name.-_"__C =-------------------- ------------•-------- Phoneme-✓ Installation will serve: Residence,4_?Npartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:*_/___ Number of bedrooms _..P. Number of baths /___ Lot size __ ___________________________ Water Supply: Public system ❑ Community system ❑ Private A Depth to Water Table Aled_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4_ Hardpan ❑ Previous Application Made: Yes ❑ No PS.—New Construction: Yes A, No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: t ante from nearest well_ ______________Distance from foundation------------------- ❑ o.compartments.......- ------Size--------•-----------------------Liquid depth----------------- ------- Capacity t Disposal Feld: .�F3nce from nearest well ___----------Distance from foundation----------------.---Distance to nearest of ine________________. ❑ {1!f`Jrt..� urr er of lines---------------------- ---- _-Length of each line------------------------•-----Width of trench--------------------- ------------- Type of filter material _------------------or__Depth of filter material- ------------------ length-----------.-_________-____-__________.__ Seepage Pit: Distance to nearest well-.11A-------Distance from foundati n___--47p_. .Distanc fto nearest lot line__. ._- --- Number of pits---- ------- -------Lining material--- Diameter-----al�1------- Depth--..,---— ------------- Cess�l: Distance from nearest well-----------------Distance from foundation-----------------__ Lining material-_.---------------------------------- El --------__-_____-___________❑ Size: Diameter------------- ------- ----------Depth----------------------------------.- ------- ---Liquid Capacity- --•-----------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line--------- ---•------------- --------------------------------------•------------------------------------------------------------------------- Remodelingand/or repairing (describe)-------------------------------------- ------------------•-•---------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------•-----------------------•----------------- -- ------------ -------------------------------- -----------------------------------------------•--------------------------------------•---------------------------------------------••----------------•----------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regulations of the San Joaquin Local Health District. {Sign ----------- --- -- �---- ------------------------------------------- --(Own nd/or Contractor) -- --- -- ----------------(Title)------. --- -------or (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 APPLICATIONACCEPTED BY-- -------------------- ---------- ---------------------------------------- DATE------ --------------- ----------------------------- DATE_ ----- REVIEWEDBY-------------------------- -------- -------- ------------ ---------------------------- ✓� ---------------•-------------------------------------. . DATE------------------ ----------------------------- Z Alterations PERMIT 155UE0._______________________ _____ ___ ___ --- Alterations and/or recommendations-- ---------- ---- --- --------- --- -------•-••-----------------------•---- ------ •----------------•- ,. ---------- ... j= -S `y!_`F- i ----- 7''- 4 _-�_ ..' -- - -----------» ------------- -------------------------------------------------------------------- .�_-=�.--------:�-----_----��------- ------- - --------------------- -- ------------------- ----------------------------------------------------------- ------ r-- FINAL INSPECTION BY: `-- •.ej-_� -------------------------------------- Date----- f 7--•- -5--- -------------------------------- 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 145446 ATWOOO