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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) i Date Issued f A licabion 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. F JOB ADDRESS AND CATION.. 1- - � '79 ----- -- Owner's Name------- --------0.9710-Vs------------------------------ ------------ -------------------------------- Phone------------------------------------ Address-_... zll Contractors Name--- --- ----- ----- - - ------ -- --- 44111--.1601-0-040-111 -------------------------•----------------- Phon '' (k Installation will serve: Residence ❑ Apartment House ❑ Commercial aiTer Court ❑ Motel er ❑ Number of living units: Number of bedrooms Number of baths . `Lot size ___- ___ --------------- Water Supply: Public system°[ ;..T•emmunity system ❑ Private ❑ Depth to Water Tablelp. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe rdpan ❑ Previous Application Made: Yes ❑± No ❑ 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_- "f---------------- ----Capacity--•-•------------------ I Disposal Field: Distance from nearest wefl_________________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: Diameter------1-----------------Depth--------------------------------- •i ! Cesspool: Distance from nI earest well:---------------Distance-from foundation________________ Lining material__-____.._.-_.____-.----___-_______-. cis ❑ Size: Diameter.-I---------------------------------Depth------------------`/-------- ---------------------Liquid Capacity------------------------------gals. Privy: Distance from nearest well......._.:------------______- -- __..._Distance from nearest building K ❑ Distance to nearest lot line------ -------------------•--- = Rem deling and/or c pairing (describe):____ - :__- _ l m --------------- x ----------- `s"� --------------------------------- 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. (Si ned � !�� tilt 9 ) �_(Ownerr Contractor) By:- --- -- ----- --------=------------------------------•- ------(Title)--- ----- (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ;r ( FOR DEPARTMENT USE ONLY { APPLICATION ACCEPTED BY-------------•------------IZ- ---� ------------ ------------•------------ DATE_.---- ) REVIEWEDBY----- -------------------------- `---------- -------�-�- ------------•---------------- ------ DATE------ ------- \ -----' BUILDING PERMIT ISSUED------------------------------- ----� ------------------------------ ------ DATE----------- , ---------------------------- Alterations and/or recommendations: ..__e� --------------- :.. . _____________________ F ,--- .r r -•---- � ------------------------••-- FINAL INSPECTION BY: - ------ - ----------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT # 130 South American Street - 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California i Lodi, California Manfeca, California Tracy, California z E3-9-21v1 145446 ATW000 1254