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t E APPLICATION FOR SANITATION PERMIT Permit 0 ___J_----- 1 (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health 'strict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinan e No. 549. JOB ADDRESS AND LOCATION--- 1 Q _-- ----__-Q--------------------- ------------------------------------------------- Owner's Name . _ Phone Address- �✓`--=t��= - -----------------------------------------------•-...... ---•-- Contractor's Name :.__"------------------------------------------------•--- ----- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: . --_ Number of bedrooms _ Number of baths _4 Lot size __-"'______________ Water Supply: Public systemCommunity system ❑ Private [—] Depth to Water Tabl9�0Off. Character of soil to a depth ofk3eef: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes E] N New Construction: Yes No ❑ \\ TYPE OF INSTALLATION AND SPECIFICATIONS: ' `` (No septic tank or cesspool permitted if public ' .er is available win 200 feet.) Septic Tank: Distance from nearest weII4-rz _ Distance;rom foundaftion------� ------Matfe�rriial �r -_ No. of compartments____ _______"_.__5ize__ _ _____ 1 -Y-.Liquid depth 7 _ ----Capacity_._ _. _ -- -- Disposal Field: Distance from nearest well_____________Distance from undation____________________Distance to nearest lot line__ ____. _ _ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-----------------------_____-__._" L Type of filter material------------------"-- Depth of fiit r aterial-------------------.--_Total length-----------------------------------------_ € � fou �__.._.Dis�ance to nearest lot line_____,___ (Seepage Pit: Distance to nearest wellQr_� D tame fr m fou elation__.._17 Q f 11 Number of pits-----/-_________/Lining material_ __ _ __!_Size: Diameter_________ p ' Cessp o€: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-__-_______-_________-___________ Size: Diameter_______________ ___De th____._._________________-___ --------------------Liuid Ca acit ..gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_._____________________-________________ ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodelin and or repairing describe :--- --------------------------- -------- --•------------------------------- --------------•---------------------------------------------.-------------------------------------------.-------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat awl,,and ru a regulations of the San Joaquin Local Health District. (Signed)------------ ------ --------- ---- ------------- ----------------------------------------------------------------------- -------------------------(Owner and/or-.Gpntra�ctor) By:--------.._•------------- --- ------ -•- ------------------------------------------I-------------------------------------- (Plot ------------------------------------(Plot plan, showing size o of, location of system in relation to wells, buildings, etc., can be placed on reverse side. -� FOR DEPARTMENT USE ONLY = APPLICATION ACCEPTED BTS -------------- ------------------------ -------------------------------------- DATE_.._ REVIEWEDBY---------------------- ----- — -------------- ------------- - ------------ ------------------------------- DATE-- e---------------------------------------------------- BUILDING PERMIT ISSUED :- • DATE------- -- Altera "ons and/or recommendations:------- --"---------- ----------------------------------------------- -----;---------------- e------------------------------------------------ - - ----- -- --�---------------------------------------------------------------------------------------------------------------------------------------- ----- --------------- V - ------- - ---------------------------------------------------------------t---------- --------------------------------- ------------- ----------------------------------- FINAL INSPECTION BY:-----Xt_j.., /-t_.£�� - Date - - jo.-1-xI- --��- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100