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APPLICATION FOR SANITATION PERMIT Permit No. ....I�-L-�l•-•-- (Complete in Duplicate) Date Issued ._l� - ✓� Appliceion 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. orf JOB ADDRESS A LOC,AjTION2._ / 1f. ---------- ----------------------------------•-------------------- Owner s Namel 4111A. �--�---. - /. I --------------------------------------- Phone--------------------------------•--- � I � ------------ -----------•-----------------------------------------------------------------•------------- Address.- 11 � f - {r-=+-- --- Phone Contractor's Name---- --------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ElOtper ElNumber of living units: __/____ Number of bedrooms _ -- Number of baths .-1--- Lot size !__ _�___ .!-- "�---------- 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 0 Clay Loam ❑ Clay ❑ Adobe Z/Hardpan E]Previous Application Made: Yes ❑ No R"" New Construction: Yes No ❑ 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--;______________Distance from foundation--------------------Material--------------------------------______._.._..._. ❑ No. of compartments------------- ------------Size------•------------------------ Liquid depth---------------- -------- Capacity----------------------- Disposal Field: Distance from nearest well...... ----------Distance from foundation--------------------Distance to nearest lot line--.._________-__. ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____-_________-. ❑ Number of pits Lining material------ --------- Size: Diametr Depth _ n Distance om foundation--J-0 material__ _...--- ------ Size: - . Cessp�� Distance from nearest well _ ._ ,� �� Size: Diameter------ -)\---- ------- -------Depth------------------------------------ - -------------Liquid Capacity---------`_(,;o_o......gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------.-----_____________._-----.- ❑ Distance to nearest lot line--------- ------- --- ------•---------------------------------r----------------------- ---------------------- \ R model ng 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, a:�y rules an- regulations of the San Joaquin Local Health District. • 1 1 - ------------------ - -----------------------------------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------•-----------------------------------------------------------------------------------(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 APPLICATIONACCEPTED BY- ------- -----------------•-------------------- DATE ------ --------------------------------- REVIE_WED BY----------------- ------------- ------ ----------------------------------------------------------- DATE-- — ---------------------------------------------- BUILDING PERMIT ISSUED-------•------ -- ---------------- --- -. DATE------- - -------------- Altenations and/ recomme ions-------------- --------- -------- ---------------------------------- ---------- <n �--------------- ---------------------------- --- - ------ --------------- FINAL INSPECTION BY:_.�L� --- ------ ------ ------------• Date..... _--.` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streat 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9- 2M 145446 AYW00. 12.54