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APPLICATION FOR SANITATION PERMIT Permit No. - ------ (Complete in Duplicate) V1 A Lt'v Date Issued P__" 3 Application 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 J08 ADDRESS AND;L ATIIOON ; - Com_ W . Owner's Name---- ----- •=Ta- �"4=----- -- �� -------V____ Phone---- •- ✓`a Address -------------- ------ ----- - Contractor's N e-------- ---------------------- ---- ----------------------------------------------------------------------- Phone-_-3----•-�� Y Installation will serve: Residence ❑' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _,%-_ Number of bedrooms _„,?_ Number of baths;_.Z Lot size ___, Q _l-________________________ tr Water Supply: Public system Community system -❑ Private ❑ Depth to Water Table,//_/_1'0tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ❑ No New Construction: ''Yesk No F] '� I 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.eys<t' Distance from foundati�n_,✓fJ_______-_Material-------__________ ________________ _ No. of compartments----____-_ _______Size__✓__� _j Liquid depth_,-�____ ,?_'__Capacity_____- _ -Q Disposal Field: Distance from nearest well _-_-- Distance 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------------------------------------------ r r See a e Pit: Distance to nearest well_ ____________ ____Distance fr m four tion-_�✓___ r� p ��-_ _...___.Dista ce to nearest lot line_____ ____ Number of pits___________________Lining materia�_y__---'-Size: Diameter____-?------------.Dept h---------/ ____.-________ Cesspool: Distance from nearest well_--------------Distance from foundation--------------------Lining material_----_______________________-________- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--------------------------gal Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------------- ❑ Distance to nearest lot line---------------------------------------------------------------•--•----------------------•-•------------------------------------------------- Remodeling and/or repairing (describe): �.Qtt�J-------------------------------------------------------------------------------•---------- ----------------- --------------------------------------------------------------------------------------------------------------------------------•.-_---------------------------------------•------------------------------------------------- --------------------------------------------------------------------------•-------------•--------------------------------------------------•-----------------•------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s, and rules nd regula ' of the San Joaquin Local Health District. -- -- - - ----- ------------------------------------------------------------------ wrier a r ontractor) (Signed)---------------• �""�' ^- By---- ------ ---• ---�� -------------(Titlel--------- - ----------- --- -- --- (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be a on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ------- -------------------------------- DATE------- f REVIEWEDBY------------------------- -------------------------•-- --------------------------------------------- DATE----- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations------------------------------------ ------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- --------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY-----------------------(__q 7�r6u------------------- Date------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" $treat Stockton, California Lodi, California Manteca, California Tracy, California f ES-9-2M 8-51 Revised W-2100 J