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APPLICATION FOR g SANITATION PERMIT Permit No. � a - _--_ ----- (Complete in Duplicate) Date Issued Applical-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. w This application is made in compliance with County Ordinance Po. 549, JOB ADDRESS AND LOCATION1_._ � 0 ------------- 'i ..: Owner's Name.__e - ---- --• --•------------- -=----- .............................. -..- Phone-.------------ - - Address - " . -- . ---------------•------- Contractor's Name. -------------- --- Phoneefy ''�- - Installation will serve: Residence Z r partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1--- Number of bedrooms --? Number of baths --/-_ a "Lot size -_--- 77 Water Supply: Public system mmunity system [❑ Private Q Depth to Water Tablet---- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Lew 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-1- _�.._ �--------.Material- No. of compartments----- ------------- -- -------__-_- -------- Size- -0----Liquid depth./ --------Capacity--A' Disposal Field: Distance from nearest well-----------------Distance from foundation---I_0---`.----..Distance to nearest lot line--_-0„'-_-- Number o{ lines---------- -- en th of each line---7 - i Type of filter material -- � g �--2X.-,I'Q.Width of trench---a- ------------------- Depth of filter material--- -le _ p �� ......... otal length----�--�''�.--�- ------------------ Seepage Pit: Dis#ante to nearest welh------------------- -Distance from foundation-_•---"----.------.Distance to nearest lot line_----__----- --_ ❑ Number of pits-----=---------------Lining material-----------------------Size: Diameter------------- --------Depth--- --- ------------•--------- Cesspool, Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------- ❑ Size: Diameter----------------------------- --------Depth-------------- --------------- ---------------------Liquid Capacity----•-----------------------gals, \{ Privy: Distance from nearest wO- - ---------------------------------------------Distance from nearest building ❑ Distance to nearest lot line---------- -- ------------------------------------------------------- , 4 Remodeling and/or repairing (describe)---------------------- - -----•--------•------------•----•---------•----------•--------•-----•--•---••----•----------------------•---------•-------•----------------•------------------------------------•---•-------------------------------------- a ----------•--------••-------------- -----------------•---------•-••-------------------------- V I.hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, and rules and regulations of he San JoaquinVLocalealth District, (Signed)• "" - ---- BY:--- = _ "Per,4444r Contractor) ------------------------ ---- --------------- ----- (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 REVIEWEDBY------------- ---- -------------- --------- ------- -------------- --------------- DATE '� BUILDING PERMIT ISSUED - raj � .� �- ------ ---- D ------------------------ --- ATE---------------------------�--- ertions and/or recommendations: �'�- ------ r - ------------------------------------------------- i .s------------- t r�:"7- ------------ ".!.�-- r� `5�.. .f- - �� { , . -------------------------"---- --- -------------------------------- 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 Lodi, California Manteca, California Tracy, California ES-9-2M 545446 ATWCUD 12-54