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APPLICATION FOR SANITATION PERMIT Permit No. •- _`u---x---� (Complete in Duplicate) Date Issued I Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Or�dijce No. 549. I JOB ADDRESS AND LO ATION- --------- 4-O------- ------- I: Owner's Name ----7 -------------- -------------------------------------------- Phone------------------- --------------- Address------------------------------- ------'�`�-------------------- ----------- ------------------------------------------------------------------------------------------- ------ Contractor's Name--------- ----------- ---------------------------------------------------------------------------------------------------------------------- Phone I= - Installation will serve: Resides ❑' Aportment House Co me ial� Trailer Court ❑ Motel ❑ Other ❑ �I Number of living units: __ um er o e rooms _w.e___ Num f baths ---_L. Lot size _____ - _ - � ------- 4-------------- Water Supply: Public system k Community system .0 Private Depth to Water Table ---- ft. Character of soil to a depth of 3 feet: Sand.❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hal!dpan ❑ n Made: Yes No New Construction: Yes ❑ No Previous Application ❑ � x , TYPE OF INSTALLATION AND SPECIFICATIONS: V ; [No septic tank or cesspool permitted if public sewer is available within 200 feet.) y Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material-------------------------------------------------- ' No. of compartments--------------------------Size------------------_--_-----_ q p---_Li uid de th-------------------------_Ca aci+v �l;I_ -----------V ❑ Disposal Field: Distance from nearest well__)tot-_1XADistance from foundation---15�0---Distance to nearest lot line _ � Number of lines______________ ength of each line____ . Width of trench------ ,' ------------- t ...... I------ - I Type of filter material----- } epth 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------------------------Depth-------------------------------- Cesspool: Distance from nearest well-_____.________Distance from foundation-------------------_Lining material__.---._•--__________V_.............. ❑ Size: Diameter---------------------------------------Depth----------------------------------------------------Liquid Capacity---------------•- -gals. , �- _ter'Distance from nearest building__________________ Privy: Distance from nearest wel(------------------------------------------ ------------ ----------- ElDistance to nearest lot line----------------------------------------------------------------------- ----------------------------------- --------------------------------- Remodeling and/or repairing (describe)----------- sem___ __ --- -4 =-----•--•- ` --IST fi -------------------------- ----------•---•----------------------------------------------•------------•------------------;G,---------------- _ II I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law50nd rules and regulations of the Un Joaquin Local Health District. ' (Signed)----------------------------•----------------------`-----L , -------------------------------------------------------Owner and/or Contractor) By:------------ --------------------------------------------------------------- ----- ------------------------------------(Title)------------------------ -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR,9&RTMENT USE ONLY II APPLICATION ACCEPTED BY ---- --------- --------- DATE -- �1 .� ---------------- 11 REVIEWED -BY---------------------------------- ----------------- -------------------------- ------ ------------------------------------- DATE------- ---- -------------•----------1---------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE----------------------------------------- Alterations and/or recommendations:---.---------------------------------------------------------------------------------------------•-----------•------------------------------- --------------- -------------------------------------- ------------ --------------------------------------------------------------------------------------------------- --------------- ii E -------•--------------------------:------------------------------------------------------------------------'--------`-------------------------------------------------------•---------- ----------------- ----1 --------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- II FINAL INSPECTION BY:----------- ------------------------------------ Date--- -- ✓-. `�' - I -------- 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, Californiall _ E5-9-2M 8-51 Revised W-2100