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.� APPLICATION FOR,.SANITATION PERMIT Permit No. ----I-------------- -- r (Complete in Duplicate) g_ 53 Date Issued ___.___.__18 __._ Application is hereby made to the San Joaquin Local Health District for a permit to cons}ruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND-LOCATION-----------------73A7---- ----(ann-k?l Owner's Namet' --''4` v g -=•---------------------- --------- ----------- -- Phone-------------------•------------•--- . F Address----- ` Contractor's Name----------------- ' Phone. - ----------------------- ------------------ Installation will serve: Residence QO Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �_. Number of living units: ---------Number of bedrooms __3-.. Number of baths _2-__ Lot size._____--1DO_T_-A-----/-SQ_�__________________.-_ Water Supply: Public system' ❑. Community:system ❑—Private f Depth-to'Water Table _10- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, ° Hardpan F] Previous Application Made: Yes ❑ No* New Construction: Yes* No E] `�� ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septic Tank: Distance from nearest well-____7_________Distance fro fol-ndstion_------- --------Matieri i� F1 No: of compartments--=------- ----- Size - --- _ i)juid depth------��---------Capacity-- �'x t + Disposal Field: Distance from,.nearest well----S�__........Distance, rom founds ion_______�r0_` - +Distance to nearest lot line------S_---___v Number of lines--••-----------, !_____--------Length of each line--- --...___ 4__.Width of trench---------20",-"----_------ I Type of finer material--------1-11..__-____---Depth of filter material-1----[1- -'�--.-__-_---Total length--------- ..-------------•---------`T 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- i----------------------- --DepAh-------------------------- ..'----------------------Liquid Capacity---------------- ----------gals. Privy: Distance from nearest well---------------------- ----------------------Distance from nearest building-----------------------::---------------- ❑ Distance to nearest lot line_________________________________ Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------- -----------------------------------f --•------•--------•------------------------------------ ------------------------------------------------- --- - - -- i ;.i " ---------------------------------------- --------------------- `-r '= ` 1 --------------------------------------------------------------------------- ------•-------- -• .. -----------------------•------------------------ ------------- 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)---- --------- -- -- - --r-----------------------------------------------------------------------------.(Owner and/or Contractor) 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---------- -- — . kREVIEWED BY----------------------------------------------------------------------------- --------------------------=--------------------- DATE ------------------------------ BUILDING PERMIT ISSUED-------------------------------------------- ---------------------------------------------------- DATE Alterations and/or recommendations:------------------------------------------------------------------------------------------... ---------------------------------------------*---------------------------------------- -------------------•--•-----------------------•---------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- -------------------•---------------------- = FINAL INSPECTION BY:f`�"!_._. .----- ----------- --------- Date-- SAN JOAQUIN LOCAL HEALTH DISTRICT J 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street 1 Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100