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APPLICATION FOR SANITATION PERMIT Permit No. } (Complete in Duplicate) Date Issued Applica+ion 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. JOB ADDRESS AND LOCATION_-_-__ V.�. -•---------•-----------------------------•- Owner's Name----- ------•-- --•--•--�--t-�--- ----•-••-- 011--------------------- ------------------ Phone--- - -- ------------ A dress--------------------•- - � t.�� SCl/------- Contractor's Name----------••----•------•--_,--- - Phone 4 ----------- --- Installation will serve: Residence [•—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _./-_ Number of bedrooms _. .- Number of baths Lot size Y rte---•- --------- Water Supply: Public system R--community system ❑ Private ❑ Depth to Water Table : ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [:) Clay Loam ❑ Clay [1 Adobe e-14ardpan ❑ Previous Application Made: Yes ❑ No W---'-New Construction: Yes ❑ No 9 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic Tank: Distance from nearest well-.____.___.__--_Distance from foundation_..___ Material No. of compar#mems_. Size Liquid deptii ---------------Capacity ; _� .a isposal{Field: Distance from nearest well......------.....Distence from.foundation_�___..__`_L Number of lines------------- __._--Distance to nearest lot line----------------- ^ -.-=----------Length of each line------------------------------Width of trench_.---------.----•----- ----------- Type of filter material___ --- -- of filter material----------.--- --------Total length_-.____._._-----_--_ Seepage P't: Distance to nearest-well .-!20).4,/-Distance om fo ndation-------7�©-�__ Distance to nearest lot line__.-____-- Number of pits-------/.___.t"_____Lining material__ _ _ -__. - 5 0 -_-Size: Diamet r---- ------ --------De to-_. Cesspool: Distance from nearest }ell_________________Distance from foundation---------- .--,----.--.Lining material---:----------------------------------S;ze: Diameter---- --------Depth------ -------------------• -------- ------------------------ ------------ -- Liquid Capacity- --------------------------gals ` Privy: Distance-from nearest well)-_.._-------------------------------------- ----Distance from nearest building g --------------•--------- . El Distance to nearestlotline _ " = - • ------- -------------=--------------------------- Remodeling and/or repairing (describe)____-------- -___-----------------------------------------------------------------------------•--------•-------------------•------•-------------------- --------------- ------------------ -------------------•---------------- ----•------ ------------------------ -----------__i_._______.----------------------------------------------------------------------------------..___...__-.__...__-.._.---------------------------------- --.______-__---__ ----- __________________ -----------------------____ _._____ --------------------------------------____ _ _________ _"_._-_____"-__._--____-__-_--___-.__--_____-___-_-__._.__--_-_.___-_--__-.__--_-__.__-"..-_-.__-___...._"_.__-.._.-___ \ •'•" I hereby certify that I have prepared this application and..that the work will be done in accordance with San Joaquin County ._.__ ordinances, S ws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------- - -- - ___ Owner and/or Contractor) '$Y:------=-------------•------------•-•---------- -- ---------- ---- �--------�-- ---- -�-��--- - _ } (Plot plan, showing size of lot, locafion of system in relation to wells, bu' in-;-s,-g-s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_C"_-___-___-__ '-"-. - ------------------------ ---- --- ------ DATE_ REVIEWED BY ------------ ------ ,` ------------------------------------ ---------------------------------DATE---�---•-----•--•--------------- BUILDING PERMIT ISSUED � ----------------------------------- - - � ______ ____ r ----- - -- -------------------------------- ---- DATE ' " ----- Alterations and/or recommendations:.__.............. ----------- --------------- ---- ---------- ----------•-----------------"-- f ---------------------------------------- --------------•---------- -------- ------------- FINAL INSPECTION '------------------ Date--. --- ---- -----------•--•- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street132 S -f � ycamore Street Stockton, California Lodi, California Manteca, 814 North "C" Street California .. Tracy, California E' ��-9 1x5446 ATW[]pp r