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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) VADate Issued __--- Applica4-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 ANP LOC TION 0% (2-9 "4 -Owner'sR --------•------- Name_. - - ------- �- --------- Phone Address-_24.... XV-------- •, Contractor's Name__:_`-: - Phone-k__'". i.. Installation will serve: Residence par ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1--- Number of bedrooms --Z Number of baths .-t___ Lot size Water Supply: Public system 4zommunify system ❑ Private ❑ Depth to Water Table J-0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes �—ilp ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest w•el�,,,,,,---Distance from foundation__lo---r_-__,Material____ __ - ._ _ _- w ---- _--. ��.. No. of compartments______ / :-'=---Size ` _ - �!___-•_--Liquid depth -- -:--Capacity Disposal Field: Distance from nearest weil�yv.,,#___Distance from foundation_-__V----------Distance to nearest lot line___ '�+ ____ �— Number of lines-------- __-- Length of each line-----;?AP-----------------Width of trench_.. ----------------------- ---------- 1 Type of filter material._ __.. Depth of filter material __--� _. Total length___-___ p ,] p ge Pit: Distance to nearest well._ ,.L---Distance om foundation___iRL$ r ' -.Distance to nearest loft line---- -------- ee a plumber of pits------/------------Lining material--- _-Size: Diameter__ ��._ � r Cesspool: Distance from nearest well---------------_Distance from foundation--------------------Lining material---__---_____--.___-___- ' ❑ Size: Diameter ,Depth-� ------------------------------------------ q h.-Liquid Capacity gals. --------------- Privy: Distance from nearest well----------------------%____:-----... ______.-__-Distance from nearest building-,--------------------------------------- ❑ Distance to nearest lot line-------------------------------------- Remodeling and/or repairing (describe)-------------------------------- ------------------- --------- -------------------------------------------------------------------------------------•----------------------------------------------------------•-------------------------•------------- I hereby certify that.) have prepared this application and thaf the work will be done in accordance with San Joaquin County 1 ordinances, State aws, and rules and regulations of the San Joaquin Local Health District. I (Signed) ----�r Contractor) I BY:.....__ . Title _ _ (Plof plan, showing size c,44, ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- --- ---- DATE-------- ';Zz REVIEWED BY DATE ;;:: BUILDING PERMIT ISSUED- -- --------'`. - --------------------------------------------------- � DATE---------------- At nd r ommendaton _----------------------------------------------------------------------------- � -------------- �. r ---------- ---------------------------------------------------- ---------------------------- -----------------•-------------- ---------------------- -------------- -- ----------------•------ - - - -- -- - -- --------------------------------- FINAL INSPECTIONBY: Date....../l-/S--`S SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-5--2M 145446 arw000 12-s4