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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issued �f._�t�'!✓J 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, JOB ADDRESS AND-LOCATIO _ ------3- - -Z------ .•^ -f Owner's Name------- --------- A---------•_-l-__,__j__4_4t `- -------------------------------------------------------------- Phone----- Address------------OL-�-/-r - -.! _t- --------------•---------------•------------ Contractor's Name--------•------ ` r------------------ ---------- Phone --------------------------------------- ----------------------- Installation will serve: Residence Apartment House I] Commercial ❑ Trailer Court ❑ Motel �) Other ❑ Number of livingunits: __Number of bedrooms __ -2__ Number of baths ___/__ Lot size _______�P--�( _ 1A je 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 ❑ Adobe Q; Hardpan ❑ Previous Application Made: Yes PQ No ❑ New Construction. Yes ❑ No P TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i,3 . 4 p �'+.-_----Size__ dation----.j-Q___-------Materialf__--- -- Septic an Distance from nearest well_________________Distan e from found l�a3 No. of com artments_____ _ - Liquid de /� _________Capacity____ - ----- _.Distance from pth_________'f___ --- d Disposal Field: Distance from nearest well____4--____ dation_____/1�_l__.__Distance to nearest lot line_____- _ ___� Number of lines__________ _ tr - Length of each line_____,�7.H v, th of trench_____-- ------------------ Type of filter material--�Jz- -f7C1_ epth of filter material__ _I___J__Total length------------/ g�-�_________ Seepage Pit: Distance to nearest well---------------_______Distance from foundation-------.------------Distance to nearest lot line___________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------- -- Cesspool: Distance from nearest well----__________-_Distance from foundation---_---------------_Lining material-------------------------------- E Size. Diameter--------------------------------------Depth------------------- Liquid Capacity gals. ------------ Privy: Distance from nearest well_________----------------------------------------Distance from nearest building ❑ Distance to nearest lot line Remodeling and/ r re )ring (d ribe):-------------"""-------___-- � - ------------ ---•-------------------------------------------------------------------------.------------- --------------- `-------------------------------- '-------- ---------------------------- -------------------------------------------------------------- --- -- ---- ------------ - 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 and regulations of the San Joaquin Local Health District. (Signed)______ ------------- --____(Owner and/or Contractor) By:- - •-•--------Ir----------- ---- 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__ -t------`- -_- /---------------- f� [e� ----- ------------------------- ------------ REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE-- - - ------------- ----------- --- -- - ------------------------ UILDING PERMIT ISSUED----------------------------------------------- - --------------------- DATE--------- -- ---------------------------- terations and/or recommendations:_______._________-_ -----------------------------------------------------------•------------------------------------------•------•---------------- --------------------------------------------------------------------------------------------------------------•- r --------- -------------------------------------------------------------------- FINAL INSPECTION BY-------------I--------` = 1 ----- -------------- ---------- Date----- ----=-- -=-------------- • - �.� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES----9-2M B-51 Revised W-2100