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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issuedf#A__- Applica+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. S49. i. Vl a JOB ADDRESS AND OCATION a '°- ' __ ._-- Owner's Name------- - - t' --------------------- ------:----------------------------------.:- Phone. I Address-------------- ...................----------------------- ------------- --------------------------------------------------------------- - Contractor's Name__Y --------------- ------- -- ------------------------ ---------------:----- -------------------------------------------- Phone----------------------------------- Installation will serve: Residence E] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: _1--- Number of bedrooms _ __. Number of baths -/---- 'Lot size ___- _________________ __ Water Supply: Public system ❑' Community system ❑ Private { ] Depth to Water Table _►SJ__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.E] Hardpan ❑ Previous Application Made: Yes ❑ No 20 New Construction: Yes ❑ No.] TYPE OF INSTALLATION AND SPECIFICATIONS: �.. (No-septic tank or-cesspool permitted if public sewer-is available within 200 feet.). ,, _ ,,;,_m,. Septic Tank: Distance from nearest well ______________Distance from foundation-------------------Material-------.---------------------------------- ❑ No. of compartments- - Size---------------------------•---Liquid depth--------------------------Capacity------ /--------- Disposal Field: Distance from nearest ell1.__�s_�__Distance from foundation_ ----------.D� nce to nearest lot lin _____________ Number of lines__-.__..__�_____�,____----------Length of each Iine___._a1`i��'.��_��idth of trench.___-�.----- Type ____��r � E T e of filter material.- y. ._ Depth of filter material_':_'-:*-_____Total length___/X_¢-'__________________________ Yp - - /��---- p - - Seepage Pit: Distance to nearest well______________________Distance from foundation-------------------.Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth..•------------------------ ------ Cesspool: Distance from nearest well_________________Distance from foundation------ -.______._.._...Lining material- _..____--------___________________- ❑ Size: Diameter-------------------=-- ---------------De Depth----------------------------------- - -------------Liquid Capacity-- ------------------•----•gals. I Privy: Distance from nearest well-----------_________-----------------------------Distance from nearest building-------------.------.___________.____._._. ❑ Distance to nearest lot line----------------------------------------------------------------- -------------------------- - # Re odeling an /or repairing (describe):__.e .----' '_ ,f ` . . ..........................................•------- ------ --- ---......_......._.-- =- .____-:=:__--------_::___- ................----------------------- `--------------------------------------------------------------------------------------------------•--------.--------------------------•---•----- - - - - - •---=-------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County k t ordinances, State laws, and rules andWregul. ions of the San Joaquin Local Health District. (Signed)... _ »✓ {Owner and/or Contractor] -------- ------ - --- - -- ------ ------- =�' " gY• = —=•. .m'-.=`= ----------- `-- ----== ------------------------------------------------." " -_ {Title) ------------------------- ---------- -- --..--- - w.,.. �p I Plat plan. showing size of lot, location of system in relation fo wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY___ _ __ __ _ __ _ _ _ ------------------------------------------------------- DATE__4'f__.. " ..___________ i REVIEWEDBY------------------------------------------------------------------------------------------------- --• - DATE------------------. -- _ $UILDiNG PERMIT ISSUED - -- DATE Alterations and/or recommendations:___-__. -__ __ ? ------------ GG 1.�f �.. ` ._..._----- ---- ------- -------------•----------- ---------- -----------= _ .. _ ""�u t -----•-------------- �------- ``�----------7------------------------------- = ........................................... -----------------E__`_�_ �'----- ----------------• ------------- ------------------------------------------- --- ---- - ----- - - ------ -- •- -- -------- - FINAL INSPECTION BY:____- ^^J ` Date------------------ -------------7-- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California f es—s 145446 nTw000 r