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2 3 APPLICATION FOR SANITATION PERMIT Permit No. __7----------------- d (Complete in Duplicate) Date Issued 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.,549. JOB ADDRESS AND OCATION... -4 ------- -�---o -- - --- Owner's Name----• ., ` l Phone Address-----J3-_=1_-- --•-----Cl.:-.....- Contractor's Nama_-- _-• ---------------------------- ff Phone. _!.! _. ! Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I____ Number of bedrooms _1____ Number of baths ._'___ Lot size ._�}d_---A-------_..Qd_____________________ Water Supply: Public system ❑ Community system ❑ PrivateBepth to Water Table f ft. Character of soil to a depth-of 3 feet: Sand JgI 6�avel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No A}— dew Construction: Yes ❑ No f�4-r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest weil;S'Q-.___Distance from foundation----/b-..........Ma�rial___ -------- No. of compartments.- �',,,,_------------Size- --- --- _--•;-----.Liquid depth-- --------------Capacity___��--------- Disposal Field: Distance from nearest well.J Qa_ .._Distance from foundation__- 1It1_..____._.Distance to nearest lot line___^_f [ � Number of lines------- -------�__._._. Length of each line___Gr __r..............Width of french...Ae ��-------.-.--.._-- ------ Type of filter material____- �________Depth of�fi{ter material-__-.__`S__'_'..Total length-----Gr__o Seepage Pit:;,, D•stance"+&nearest`well-`_._`______, _.__---Distance from foundation___________________ Distance to nearest lot line------------------ ❑ Numbe of pits----------------- ---lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool:`- Distance from nearest well----------------- from foundation................... Lining material------.----_---__._.____.__.________- ❑ Size: Diameter ------------ - - ------ Depth----- --------------------------------------------Liquid Cape'city--------------------- ------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------- [❑ Distance to nearest lot line---------------- --- - ---------------- ---:--•-------------------------••------------ Remodeling and/or repairing (describe)___________________ _I ------------ --� ------------------------------------------•-------•------•----------------------------------------------------------------------...._ -------------------------------------------------------------•---- ------------------------------------------ ----•----------------•----------------------- t� 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, and rules and regulations of the San Joaquin Local Health District. . (Signed) ------ ------------------------------------- -----•---------------------- ,Contractor) By:....._... -•----- ----------------------------------------------(Title)------------------------------------------------------------ ,'(Plot-;plan, showing-size of lot,lacjotion of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEP.A TMENT USE ONLY f APPLICATION ACCEPTED BY.-.--.-. ®r c ----------•-------- ------------------- DATE- --- ------------------ REVIEWEDBY------------------------------------ ------- ------- --------------- ---------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------- ------------------------------------------------... DATE--------------------------- Alterationsand/or recommendations---------------------- --------------------------------------------------------••---•-------------------------.-..------------------------..._ ------------------ ---------------•-----•-•----•----•---------------•--•----------------- -----------------------------------•---------------------------••--•----------•---------------------------- -----•----------•---•-•------------------- --------------------------------------- -------------------------------------------------------------------•----•-•---------------------------------------•-•------.-.----------•------------ --------------------- •--------------------------•------------------.------------------------------------------------------ -------------- ------------------------------------------- ---------.--------•-------------------_--.------------ •--- FINAL INSPECTION BY:- - --- ------------ -- ., __. Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Sfreet 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manfoca, California Tracy, California E5-9-2M 145446 ATW3DD 12.54