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APPLICATION FOR SANITATION- PERMIT Permit No. . --------1-1 --.__. (Complete in Duplicate) Date issued _--/--._-[� -�- Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This pplication.is made in compliance with County Ordinance No. 544. J013 ADDRESS AND LOCATfON- '4 ----- - - - •- -[.�- ..-------------- Owners Owners Name---- �. ----•--- - Pone Address.- I ------:t� .z> .- / .= 4e _ - ------------------------------------ Contractor's - ------------••-------•- Contractar s Name --- 2.t - C"rC-----_' - Phone.?`?_.- f/ _ ❑ P ❑ ❑ Trailer Court ❑ Motel ❑ Other p_ Installation will serve: Residence Apartment House Commercial ~ Number of living units: _------- Number of bedrooms -------- Number of baths -------- Lot size Water Supply: Public system ❑ Community system ❑ Private R-'__D`epth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan'o Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ a TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t p / �` _. Material ------- • Septic Tank: Distance from nearest well.,--_--_--__--_Distance from foundation-- -- No. of compartments—Z. ---------._Size-- ��' - -- -~ -Liquid depth_ f----'-----Capacity_ --------, Disposal Field: Distance from nears twell- r--C °'--.-Dista from of undation_�'��?---- Distance to nearest lot line-/O-'_... � Number of lines----- - -----------t-% -Length of each line--- .-------- -----_ Width of trench---j -/--------------- Type of filter material��`---__Depth of filter materiaL_�.�-------------Total length_-�-�� Seepage Pit: Distance to nearest well,- �-�?- --Distance from foundation--6-n. .....Distance to nearest lot line- 7 Number of pits------�------__Lining material-f A��Aize: Diameter----4/c�i 10___-----Depth..- !r-"f ----7__Lr�_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------- ------------- ❑ Size: Diameter-------------------------- - ---------Depth------------------------------------- --------------Liquid Capacity-. -•----------------•------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_ _------__---------.--_-----_----------, ❑ Distance to nearest lot line--------- - -----------------•-----------------•--------------------•----------------- k\ Remodeling and/c,,r. epairi g (descrilae}:_." � __----_ zxr- -C �-r --•_ .,1Jr�t��r,.'` _4.,• ------- -----------_- . f ----------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------•--•-------\` \[ -------------------•---------------- --------•------••---•-------------------•-•------------•---•-•-----------------------------------------------•------ -----------------•----- �! 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}_.- - ---------------DAY-NI_M-------------- - --------- L (Owner and/or Contractor) Septic lank Service r B 1Vr ^�/Title ��_ ,_=° -------- g (Plot plan g s,ie oo1 la. dada Cd(ts em in relation too wells, buildings, etc.,/can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- _ -._. ----------------------------------------- DATE------------- -, - -- REVIEWED BY -�__ -_rte------------- - DATE - --- - ! J ------------------ UI DIN PERMIT ISSUED ---- - -------------------------------------- ------------- DATE Alterations and/or recommendati ns-----------------_ . ---------- { t - --------------- - ---- - q -- = = --------------- 4 4 SOP - u--------- #� y . ----- -J S FINAL INSPECTION BY:. q -----_------ - Date12 --------------------- --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT T 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 9 1a1-.AT..00