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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in.Duplicate) Date issued /A�pplica-lion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. s application is made in compliance with County Ordinance No. S49. NB ADDRESS AND QCATI ____' •- r�r..-h_ 1 i'7 ��b3 Owner's Name_ -------------------- --�� R ----- Phone' -- ----------------------- Address. ' �•�y CC�� Contractor's Name_____ _. - ' ,llw -*� r • ------•-;;if---�...='�.—v— --------------- --------------•- ------••-------•----------- Phone-- ----- ---Q__.�_-�� 7 Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _______ Number of bedrooms -------- Number of baths ._1___ Lot size Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _,.O ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No,2k. 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__ d_1lf Disfance from foundation_____ZO__ __._Material14 ,__ No. of compartments_--.---- ----------Size----��---A-14-Liquid depth------- ---------Capacity_--____5 c3O-- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line___________.____ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench--------------------__---- - {- Type of filter material------ bepth of filter material-----------------------Total length___________________--____________________. Seepage Pit: Distance to nearest well____f/�¢.8 Lance from foundat-o ____/__lo___'____.Distance�to nearest lot line----- ------- Diameter /_- Number of pits.___________________Lining material__C�_�i Diameter____ „ --------Depth_____c.---.�� ' ------------------ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material----------------------------------- Size: Diameter------------------------------------- Depth--------------------------------- ------------------Liquid Capacity...------------------------gals. r - Privy: Distance from nearest well ___---_-----------------------------------------Distance from nearest building------------------------------------------ D Distance to nearest lot line-------- 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-laws and rules and regulations of the San Joaquin Local Health District. (Signed) ,f `" 1 " ��+--1------ (Own and/or Contractor) r _ "�..r ------------------------ -- r gy �-�.W- - -' - +�'•= ,C�+- ----- --•-(Title)------- ` c---------- (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._ REVIEWED BY -- ----- - DATE------------�� BUILDING PERMIT ISSUED ------- --� .'--------------------------------•--------------------- DATE.----------- -----•- Alterations and/or recommendations_________ __________ _N .------------------•---------•-----------•-------------•--..----- _ --•• ------ -------•---------••------------•-------•----------••----------------------------------------- -------------------•----------------------------------------••---------------------•-------- ----•-�\----•-----•-------- ----•-------------------------------------------------------------------- - - - - FINAL INSPECTION BY:- Date !- �i� Sc SAN JOAQUIN LOCAL HEALTH DISTRICT f30 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100