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d�J' �y'yl APPLICATION FOR SANITATION PERMIT Permit �- ff n (Complete in Duplicate) Date Issued (((wwVNN Os-Cp^O2A^O ir Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he 'n des d. This a plication is made in compliance with County Ordinn a o. 549. ��//� JOB ADDRESS AgD-tOCATION . . .. .____-- -- // Owner's Name / - . ------ ---- .............. one �� - -- - ---------- Address-------------.. -- . ----- --- -- - - -- -- - - -- -- ------- Contractor's Name - -- -- 4-..._---------------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 r Number of living units: _�._ Number of bedrooms-4- Number of baths -./- Lot size __.-... Water Supply: Public system E] Community system ❑ Private Depth to Water Tabl _ Gft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobHardpan ❑ Previous Application Made: Yes ❑ NO New Construction: YeAl�No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public iaVer is available within 200 feet. Septic Tank: Distance from nearest well ..... _.... iifance from foundation--_. ...r. Materia.... .--- T:4. r ------ - .Ll. y . No. of compartments.... ....... ...... . 'ze.(p.�. y�er-llLiqui de th.. ., L/'.- ---'-Capacity_.. !r!.. 1 -- - tY - Disposal Field: Distance from nearest well _-. istance from foundation. Distance to nearest lot line..�a�ij Number of lines............. ...... . .....Length of each line.... .. - Width of trench�..q. 2� Type of filter material . --__ -----Depth of filter material---- _--r----_-_ r Total longfh- /f?��---------------------- 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____.--_-.---.--_.____........ ❑ Size: Diameter... ................._.............Depth............................----_------------Liquid Capacity......_----_-_gals. Privy: Distance from nearest well..................—............................Distance from nearest building-----------___.____._..._.._..._.._. 1 ❑ Distance to nearest lot line....----------------------------------------------------------------------------------------------.... ....» .._. Remodeling and/or repairing (describe):............... .. -------- ----.....-................... ..............—-------------------------------------------------••---01-•....................---------------------------------------------------------------_------------•------ --------------------•- ---- --------------............................. -----------------------------------------------------------------------------------------.......................--.................... I hereby certify that I have epared this application and that the work will be done in accordance with San Joaquin County ordinances, State , and rul nd egulations of the San Joaquin Local Health District. (Signed) (Owner and/or Contractor) By....----- e. . i--------` ..................................................-------•----- Title - r i ' --`---- --- - --- -- - - ( J- ---- ter---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p aced on reverse side] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. --_---------------- ........................................................ DATE.- -- ----- --------------------- ---- -_.-------- REVIEW ED BY-------------------------_ - . DATE--- ---------••----------------- - BUILDING PERMIT ISSUED..................,. ......--------------------------...---------............-......-------- DATE----- ......... — - Zs..,_......... Alterations and/or recommendations:...............................................................................----.___----•---••••--......---"............•..........--....._....-- --.........................................................................................--`-`--............._......--......................-............ ............._................_................... ------•----------------•-----•-------.-....----------------...-------------............-------------------------------•---•---------------....--•-----•-------•--------------------_--------.------------- -------`-••---------•-------_.............................................._--------------------........................ ---------------------------------------._............................................... ...........................................................................................................................................................................................................-............._. FINAL INSPECTION BY:---.^" � ^--------- Date........ _....--- y -: SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Sfreet 814 North "C" Slraar Stockton, California Lodi, California Manteca, California Tracy. Colffafala ES-9-2M 8-51 Revised W-2100