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APPLICATION FOR SANITATION PERMIT Permit No. ----------I-J____---- _ (Complete in Duplicate) Date issued.. � I 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 Ordinanc No. 549. JOB ADDRESS AND LOCA �1 --- � t -Owner's Name.. -- Ph � l Address------------------------ ,------- - ------- Contractor's Name... --------------------- ------------------------------ - -•-•-------------------- ------------------------------ Phone-------------------- II- ------ ---- Installation will serve: Residence ❑ Apartment House ❑ Commercial Traier Court ❑.. Motel ❑ Other ❑ � I Number of living units: _.--____ N ber of bedrooms -------- Number of baths ________ Lot size --- C3_________II- i Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft... .Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe al dpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest welL, -Distance from foundation__--------- terial-_-________:.____-.__ .___._ i _No. of compartments ------------- e__ Liquid depth___ _ ..__-..-._Capacty_ ------------ (Ell ---__, J Disposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line__I----......... h ❑ Number of lines-----------------------------------Length of each line----------------------------.-.Width of trench-------------------- -------------- Type of filter material------------------------- of filter material _______._.._..-------- otal length--------------------------- ------------- S Distance to nearest well----------------------Distance from foundation----_____________...Distance to nearest lot line-JI_--------_-- Number of pits----------------------Lining material-----------------------Size: Diameter--------------.--------Depth..................[------------- Cesspool: Distance from nearest well-----------------Distance from foundation...._ , .-_-----.--___Linin material-_.._______.____.-----�----------= I]'`. Size: Diameter---- -------------------------Depth--------------------•------------------------- -----Liquid Capacity----•---•-----------I gala. Privy: Distance from nearest well .................._---____----___.._.-___.._---Distance from nearest building--------------------------i_.-..-.__._-_. El — =Distance-too-nearest lots.line----=--- -—-------------------------------------- ---------------I--------------- l ------------- Remodeling and/of repairin (describe): - �- .. � ---------------------------------------------- ;IV �� - - ••' -� _ ----i ------- -------------------•----------------------- t ------------------------------------• ... --------------------------------------------------------------f=--••----•--------- = --------------------- ---------- --•-------•--•-------------------------------......------------------------------------•-•--•--------------------- ----------------------•---•------------------- ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San_JoaguinI County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------------------------------------------------------------------------------------- --------------------------------- =--------(Owner and/or Contractor-) I i By-------------------------------•----------------------------------------------------------- ----------------------------------------(Title)------------------------- --------------- - �--------------- (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 --- j --------- REVIEWED BY--------------------------------------------- ----- DATE .__. .- I BUILDINGPERMIT ISSUED------------------------------- -------------------------------------------------------------------- DA7 -------------•-----•------------------------I------------•- Alterat' and/or r io s:_--- ` -------- -- - - - ------ ------------• ----------- i ------------ j -•- -- -------- - r__ "'____r - ----- ---�-•--- � _ "_n_`_ - -------• - ,-t tea.- �- --- ---- ----°t -- --- ----------------------------- --------------------------------- L------------ ------------ . r R-)47;'------------------------------------------------------------------------------------ .II---------------, If FINAL INSPECTION BY: 9 - ;I- SAN s JOAQUIN LOCAL HEALTH DISTRICT ;I 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California EU-9-2M 145446 ATWOOP 1254 11