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APPLICATION FOR SANITATION PERMIT Permit No. .-_ .,�"-•" r (Complete in Duplicate) / Date Issued >>�/ -3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wort; herein described. This application is made in compliance with County Ordina c No. 549. # JOB ADDRESS AND LOCAT? ---- �� -__2_ Owner's Name-------- -=---•------•-- y ----------- ----•-------- - -••------ ---- ---- ------ -------- Phone_ _-0 „`� Address_----------•-••- 7-�'5-7----- _ - -- " .. .,�(� Contractor's Namel---�'-�*•-��•- • x �` io , 4� ------- - u' r ` Phone --- Installation will serve: Residence partment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --j--- Number of bedrooms r— Number of baths _- X � r ____ Lot size lag__ -,- --_--_ - Q Water Supply: Public system ir<ommunify system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ SandyLoam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ o \� TYPE OF INSTALLATION AND SPECIFICATIONS: V (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tyk: Distance from nearest weli__:7!7�_Distance,, from foundation____4� Material_-�-,-�% ' No, of com artments__-_____ � � � -�"""" --------•• p — __X ------Liquid depth-----" pc Disposal Field: Distance from nearest well_=-"�� "�--------------Capac�ty___.ri-�Q-"-"_---:"• l Distance from foundation__ _-1-- �,---- ----------------------- Type " f/ Is.Number o{ lines----------------1 Q .Distance to nearest lot line__________ i --- ----- Length of each line--- t]- - --+ Width of trench------c---�------- Type of filter material",---- -----Depth of filter materiaL__ �-�f __.Total length___.____.' Seeppaggee Pit: Distance to nearest well-------.__-___-.-____Distance fr m oundation-_____.S_Q_____.Distance fio nearest lot line__.-~ L7 Number of pits.___.___./_.__---___-.Lining material_Q��-Size: Diameter_---,.�� Deptn .... Cesspool: Distance from nearest well_______________ _Distance from foundation__.---________--__.Lining material_-.______----______.___-- - ' ❑ Size: Diameter-------'---------- -------------------Depth----------------------- -- --- K Liquid Capacity Privr � - - - ---- - ------ -- q p Y- --- -------------------- Y= Distance from near=est well------_----_--------------------------------------Distance from nearest buildin 11 g Distance to nearest lot fine Remodeling 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, State laws, ules a d regu tions of the an;;;;; Joaqu' Local Health District. (Signed) - -------------------------------------- - ---- --------------- ----(Owner and/or Contractor) 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--- - --- - REVIEWED BY-------------------------------- --------- ------------------ ----�.-S .............................. DATE_ - ------ -- BUILDING PERMIT ISSUED-------------------------------------- -------------------•----- ------------------------------------- DATE-------------------- lter ions and/or ecommendations:._ __ -" ._ - ---.._ f ---•------ °�`i '" °1� '� » _ -��' "P - - -------------- ---- _._. __.. '�' - --------------------- - -------------------------------- -- _.___.._- r_ FINAL INSPECTION BY:---------- _-•-----1 � ------------ Date--- ----- 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, California ES---9-2M (0'52 Revised W-2100