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APPLICATION FOR' SANITATION PERMIT Permit No .. - :..�.. J2 �' ... (Compl0e-in-9npifcst�j / f'" A Date Issued .__-_____'__ I Application is hereby made to the San Joaquin Local Health District for a permit to construct and insWl the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------- -------- --- = ! [ y '�' ----- Owner's Name - ------ Phone ' Address �f- - ------------ -----•-• ------------------------------ - -•-----------------------------------•--•-------------------------------•--------- Contractor's Name----- --------------• --------------------------------------------------------•------=--------------------- Phone----------------------------------- Installation ---•- ------Installation will serve: Residence �artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Number of living units: J. umber of bedrooms A_. Number of baths Wateot'size ----- -- ----- Water Supply: Public system [Community system ❑ Private ❑ Depthable -------- ft. , Character of soil to a depth of 3 feet:' Sand [-] Gravel E] Sandy Loam [I Clay Loam E] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes o E] New Construction; Yes ❑ No r TYPE OF INSTALLATION AND SPECIFICATIONS: 369 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) { Septic Tank: Distance from nearest weli--=-_—__-___Distance from foundation___�Q_�_ :____.Material__ - _____._ _ ,/ RjI No. of compartments----- — _ - - ----------Liquid depth ��.��------Capacity_____4dd...... Disposa Field: Distance from nearest well_- _____.Distance from foundation---------------------_-_�___._-Distance to nearest lot line____...._____. Number of lines------------Y______ ________Length of each line_______.&r?._- Width offrench___________ e'__.__-______�T Type of filler material __&� Depth of filter material-- -----/--?'----Total length____________________---!-----_-____.___._ ' Seepage Pit: Distance to no well-----------------------Distance from foundation-------------..___.Distance to nearest lot line----------------- El --- __..__❑ Number of pits------------------- --Lining material-----------------------Sizer Diameter-------------------------------------Depth----------_--------_------------- Cesspool: Distance from nearest well_________________Distance from foundsfi..n_t'°_ `-----------.Lining material---_-__-,_______.._.___..___.____.__. ❑ Size: Diameter,---.----- `::------------------ ------Depth----------------- - t'-------------A----- :__Liquid Capacity----------------------------gals. f . Privy: . .�< '�Distance'from",nearest well-------------------------------------------------Dis ante from nearesr building------------------------------------------ ElDistance to.neares.t..Iot_line---------------------------------------------- ----------------`-= ---•------------------------------------ -------------------- Remodeling and/or repairing (describe)-- --------------------------------------------------=----•=---•--------------------=-- --- ------{------------------------------- ------ - ----------- h —. -: -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 laWadd ules ulations of the San-Joaquin Local Health District. _ (Signed}_ 4?W F-- -- _____.(Owner and/or Contractor) ___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---- DATEE S;3 REVIEWEDBY--------------------------------- --- ------------------------------------------------------------------------------- DATE------------------ ----------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------- ---------------- DATE.------- •-----•--------------------------------------- Alterations and/or recommendations: j '- ------- - `` ".. _ -mss . - ---------•------------------------- -------- ---------•-------------------------------------------------------------------------------------------- --------------------------------------- --------------------------------- ----------------------------- ------------------------------- --- ---------------------- --•------------------ -----------------------------------------•------------------------------------------- FINAL INSPECTION BY...---------- �"� ?``--------------- Date------ --------- �C`. --- -- ' SAN JOAQUIN LOCAL HEALTH DISTRICT ,. f . 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street s Stockton, California Lodi, California Manteca, California Tracy, California e E5-9-2M 10-52 Revised W-2100