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APPLICATION FOR SANITATION PERMIT Permit No. (Corriplefe in Duplicate) 9 . pate 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 Counfy Ordinance No. 549.E J JOB ADDRESS AND LOCATION •�� . '�� /------ - - Owner's Na' -11, � }E -- - ------------------------------------------ Phone_..--------------------------------- Address---------------- _70 _ .---`?O Contractor's Name-- -----• --._.. - - -------------------- Installation Phone - -lid 7- -will serve: - Residences Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ .Other ❑ Number of living units: /.___ Number of bedrooms '�_ _-Number of baths ___1___ Lot size --------?(0-------- .� Water Supply: Public systemA Community system ❑" Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,Z __Hardpan ❑ �:r- Previous Application Made: Yes ❑ No1;2- ..New Construction: Yes ,_No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well__ __ ?y1RDistance from foundation_-.A>---------ma erialx ____________ ----------- No. __ _.No. of compartments_.___ __ _________ Liquid depth------ --------Capacity------91or ---- Disposal Field: Distance from nearest well__1&1stance from foundatian__,/_'� ._- Distance to nearest lo} ----- Number of lines___________ __ _ -----------Length of each line------- Width of french_______��. -.._______".___ Type of filter material___ ____ � Depth of filter material_____ _.__g _."."__To}al length___-.. � Seepage Pit: Distance to nearest weff_.� pisfance faun goon__ __ _ __�_ Distan e to nearest lot line._._- -�... a� Number of pits____../------------Lining material___�.�: Diameter_4�____....__Depth-_.. _ _________ .� Cesspool: Distance from nearest well_________________Distance from foundation-_-__- __,Lining material-_._____________._.__._.--._-______ ❑ Size: Diameter--------------------------------- ---Depfh__.-------------------------- ----------------------Liquid Capacity--------------------- 9als, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------:---------------------- ❑ Distance to nearest lot line------------------------------------------------------------------- ; u= Remodelingand/or repairing (describe)--------------------•--------•----------------------------•--.._....-•--••---•--------•• ----•• -- =--=-----------•----•-----••----------..._................. -•,i -----••-- -------------•----- ----------------••----------------••--------------------•-----•----------------------------•---•------•----•----•---•---•-----------------------...----•--------•---•------------------- I hereby certif a have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aws, d rules tnd regulations of the San Joaquin Local Health District. (S �_ -------------------------(Owner nd/or Contractor) - --- -- ------- . •--_._.. . - ---------- ----- Title 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----------_�------------------------------------------ REVIEWEDBY--------•------------------------------------ ------ --- . ------. -- ------------------------------------------ DATE----- -------- - BUILDING PERMIT ISSUED--------------- DATE---- �= - - Alterations and/or recommendations:-------------- --------- ------------------. -----------------------------••-----------•--------•-- \ ---------------------- -•---------•-------------•--------------------•-- -----------...------ ----•- ----- \ ------- -- -- ----• / ---- ------------------- -- ------------------------------------------ -------- ---- - -- --------------•--- ----------------------------------------------- - --------------- ---- -----------------------------------•-------------- FINAL INSPECTION BY:..-----15 •17- S 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 E°--$ 1a5416 ATWOOD y