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APPLICATION FOR SANITATION PERMIT Permit No:_-�q_,7.___.- (Camplete in Duplicate) Date Issued-5/-a-0/ 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. JOB ADDRESS AND LOCATI N - r t2 Owner's Name ----------- - ------------------------------------------ Phone------------------------------------ Address ----------- - -- ------------------ Address -----------------------•---------------------------------••----------------------------••--------------------------------•------- Contractor's Name------------------------------------------I ------------•---------------------•------------------------------------ Phone---------------------------------- Installation will serve: Residence g+00 partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __lf-_- Number of bedrooms ---- -- Number of baths -_�._-_ Lot size _____ w -J/�„ _.__._______________.______ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeffr"Sardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pp61ic sewer is available within 200 feet.) Septic Tank: Distance from nearest well_____ '__Distance from foundation--------------------Material -___.____________________-_-_..___________.____.� 44— No. of compartments------------N---I------- ---Size-----------------------•--------Liquid depth-------------------------Capacity----------------------- Disposal Field: Distance from nearest well-.f�-�-(tDisfance from foundation.-___---------------Distance to nearest lot line----------------- „ -- Number of lines-----------------------------------Length of each line------------------------------Width of trench---.------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length---.---••-------------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------........ Distance to nearest lot line-----------------. �•IV ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------.-------- ___________-_-- cesspool: Distance from nearest wellMWinAistance from f ndation___-1-!__ Size: Diameter_ ming material__.__ -++--.- l 'G _.._!___ __. Liquid Capacity j- ----Depth_;--------� ---------- - - -------------- 9 p tY----------�--�--Y--gals. Privy: Distance from nearest well--------------------------------------,---------Distance from nearest building-------------------•---------------------. ❑ Distance to nearest lot line----------------------------- Remodeling and/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,laws, and rules nd regulations of the San Joaquin Local Health District. YI 1 (Signed)- ------- - -- ov"'n _(^------------ ------ ----- -------------------------------(Owner and/or Contractor) B :- ---------------4----- - • --------------------- 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 APPLICATION ACCEPTED BY - ------ DATE--------------�- 4- ---- REVIEWEDBY--•-------------------------------- --------------------------------------------------- ------------------------------------- DATE---------------- BUILDINGPERMIT ISSUED-----•----------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:_--_--------------------------------------------------•----------------------------------------------------------------------------------------- ------------------------------------------------------------- --------------------------------------- --------------------- ----------------------------------------------------------------------•------------------------ -------------------•-------- FINAL INSPECTION BY:------ --------ff RP�_�_# "'. -------------- 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 ; ' Revised W-2100