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APPLICATION FOR SANITATION PERPMIT Permit No. _- _____-___________ (Complete in Duplicate) LY Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDOCAT N - ...-. Y" Owner's Name----------- -- - -s---- -------- •-- ---------- ------------------._ ------------------------------------------ Phone----------------------------------- Address------ � -------------------- -------- -W---------------------------------- ------ - - ----------- ----------- Contractor's Name,_. -_ _ --f - C �' - = Phone ,l lam Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_[] Number of living units: _l___ umber of bedrooms l_____ Number of baths I--- Lot size ___&Z� V_�--�--�------------------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. or Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Adobe Hardpan ❑ �7 I Previous Application Made: Yes L] No Sand Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic er is available within 200 feet.) 1 Ma# r'al ----------------------------- Septi� Tan . Distance from nearest wel __ _��-_--=-l-Distance,fr m fo ndation__-_�__ f --. �/ No. of comparfinents____�___ /r r_-Liquid depth_____/__ -___Capacity Disposal F' Id: Distance from nearest well/r(_(J " { stance from foundation- - ----------- r_______Distance to nearest o� I Number of lines_________ _ ---_ ength of each line-_______ __CJ ________-__-Width of trench_ ___ __�______________________ 3e Depth of filter matenaLZ_F-_---------Total len th___ ___________________________ Type of filter material_ __ ____- pg Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------------_------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- 11 Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___________________..______________-___-. ❑ Distance to nearest lot line------------------------------------- ------------ -----------------------------------------------•.-------------------------- Remodeling and/or repairing (describe):------ �--- �.._ i ---------------------•--------- --------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ._.. ---------------------•-------------------------------------------•------------L------------------------------------------------------------------------------- ----------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ,I s, and r les d regulations of the San Joaquin Local Health District. P (Signed}...... v[r/- -- / `' � '--*f,41------------------ -- --------------------------------------- Owner and/ r Contractor) Title_-- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY- --- ---------------------------------------------- ------------------------------------- DATE ---------------------------------------------------- REVIEWED BY------------------------------- ---------- - ---- ---------------- - --------------------------------- DATE-----?--•"----- --- - ------ -------------------------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------- ------------------------------------------ - Alterationsand/or recommendations---------------------------------------------------------------------------------------------------•------------ --------------- ----- ---•----------... ----------------------------------------------------- ------------------------------------------------------------------------------------------------•---------------------------------------------------------------------- ---------------------------I------I——---------------------------------------- ----------------------------------.-----•---------------------•----------•-----------------------•---------------- - ---•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- - -------------------•----------------- ---------------------------- -- ------------------ - ------ • -------- - ---------- -------- -- ------------------------------------------•-- FINAL INSPECTION BY:----- ------------------------------------• Date------------------------ ,. ..-�----- --—----------------------- 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-9-2M 5-51 Ravised W-2100