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APPLICATION FOR SANITATION PERMIT Permit No. _ __,r._. (Complete in Duplicate) �� u� Date Issued -----ri - --------�.--- i 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. -4 JOB ADDRESS AND LO TION ..------- ---�-�--- ---- -'---•-----��---- --- -- ----- - Owner's Name - Phone---------- ----------------- Address =_ --- ---------------------------------------------------------------- w �... Phone_ . 3 Contractor's Name-----------------• --- --- •,a --------- " � IInstallation will serve: Residence ❑ Apartment House Co mer is Trai er Court ❑ Motel Other ❑ _ a Number of living units: Number of bedroomsCZ7 Number of bath�lf Lot size ._,,� - __ G1 ----------------------- Water Supply: Public system ❑ Community-system ❑ Private Depth ter Table�� ft. Character of soil to a depth of 3 feet" Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ AdobA4k Hardpan ❑ Previous Application Made: Yes ❑ NojV New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Q ----_.....Material--- .. ------------------• Septic Tank: Distance from nearest well__,_---__.__Distance fro foundation___ __ __ No. of compartments--_ ------Size/#>1 / -0--------Liquid depth-_._-F------------------Capacity.., - rfoundation { e r Disposal Field: Distance from nearest well-_�0 -._.Distance from -------- -------Distance to nearest lot line___S-_-____ Number of lines___:__-___r__---_.._- ------Length of each line---------- ._�__--_____.Width of trench - _ ----�, --------------------- Type of filter material�-------Depth of filter material---/j-----10-------Total length--------- ------------------��'� Seepage Pit: Distance to nearest well. --Distance f m fo Distanceation�d__-_-___. to nearest lot line- .l�___- NrNumber of pits---- - ----------Lining materia.---Size: iameter-_- ---------le ---Dept'n_--- ................Cesspool: Distance from nearest well-----------------Distance from foundation---------- -______-.Lining material------------------------------------- j ❑ Size: Diameter--------------------------------------Depth----=------------------•----------------------------Liquid Capacity-------------------------- gals. Privy: ell Distance from nearest w -__.-_______----------------------= Distance from nearest building-- --------------------------- --- I ❑ _ . � Distance to nearest lot line- --------------- - ---------------------------•---------- ---------------------r-------------------------------------- Remodeling - ---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 and a nd regulations of the San Joaquin Local Health District. ----------------_--------- ___Owner a&nonlracf(r) (Signed} - - {------ ----------- ---------------------------- BY= ----- - [Title) --- �'------ ---(Plot plan, showi size of lot, I cation of system in relation to wells, buildings, etc., can be p c on reverse si F PARTMENT USE ONLY a I -- ----------- - I APPLICATION ACCEPTED BY----------------- - -- ---- ---- ------------------------:-------------------------- DATE------ _a; REVIEWEDBY----------------- ------ ------------------'----------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------------- ---------------------------------------------------- ------------------------------ DATE-------------- --------------------------------------------- Alterations and/or recommendations:---------------------------------- -----------------•-•----- -----------:------------------------------------------------------- -•---------•-------------•------------------------------ ------------------- --- --------------•-------•---------------- ------------------------------------------------------- ---------_-------------------------------------. ------------------------------=------------------- FINAL INSPECTION BY:. Date-- ---`!7-------------------------------------------------------------------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 13o South American Street 30o West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M io-52'Re-vis'ed W-21'00-�-