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APPLIATIO,N FOR SANITATION PERMIT Permit No. -- - __I:_-- � � (Complete in Duplicate) � I ` Date Issued ----,�-6- -�� �A`pplica}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 Ordinan e No. 549, JOB ADDRESS AND LOCATION___-- �f �z f ' ----- ------ ---------------------------------------------------------------------------------------- Owner's Name--------- 'r ---- ------•----------= --------•---------------------- ----- Phone------------------------------------ Address-------------------------------- ---------------------- ------Address--------------------------------' -------=--------------- ------------ ---------------•--------------rt -------------------- ------------------------------------------ Contractor's Name - = ': "= - == =a_..w ----- Phone----------------------------------- f - 3 ` Installation will serye: :Residence [A Apartment House ❑ Commercial'❑ Trailer Court ❑ Motel ❑ Other ❑ } Number of living units. j---- Number of bedroom's -I. Number of baths--------- Lot size --------------------------- ;3 Water Supply: Public;system ❑ Community system❑ Private U;�-repth to Water Table V-0--ft.` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ i Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[ff'-Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes E] No _ TYPE OF INSTALLATION AND SPECIFICATIONS: I4 Is (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------DistAcefrom-foundation------------------.-.Material---------------.--.-----_--_.-._-_-______-----. ❑ No. of compartments--------- - `_-._-Size-_2-�------ ..Liquid depth Capacity Disposal Field: Distance from nearest well...... ......... from foundation--------------------Distance to nearest lot lirie.-_....._--,__._ ❑ Number of lines--------------------------"`t_---Length of each line------------------------------Width of trench----------------------------.-_.--- Type of filter material---------------- ----Depth of filter material----------------------- otal length------------------------------------------- Seepage -_-_-___-___._------.------ ----.- 4 See a e Pit:- Distance to nearest well---_`---------�----Distance from foundation----------- ------Distance to nearest lot line_____--.--------_ ❑ Number of pits----------------------Lining material-----------------------Size: D.iameter------------------------Depth------------------ Cesspool: Distance from nearest well-----------------Distance from foundation------------- -------Lining material-----------.-_-.---------------------- 0 ❑ Size: Diameter--------------------------------------Depth------------------------------r--------------------Liquid Capacity---------------------------- 6 . Privy: Distance from nearest �ryell:__��.--��--•-----__-.------._Distance from nearest buildin �4�------------ - - g Distance to nearest lot line--Rr G_.._______------ ` ' ° ---------------- -- Remodelingand/br repairing (describe)---------------- ---- -----------------------=----------------------------------------- --------•-------------•----•------------------------------------ ---------------------------------------------------------------------------•-------------------------- ------------------------------------- ---------------------------------------------•-------------------------------------------------------------------------------------------...------•--------------------------------.- r. 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) ---f ir---------------------------------------------------------------- ------------ --------(Owner and/or Contractor) N 13 ----------------- -------------------------------------.------------------------------------------?-----------------(Title)---------------------------------------------------- (Plot •-----------------------------(Plot plan, showing size of lot, location of system in relation to wells, buildings,-etc., can be placed on reverse side). J FOR DEPARTMENfUSE ONLY APPLICATION ACCEPTED BY--- ---------------------------------------------- DATE --------------- REVIEWED BY -------------------------------------------------------- DAT w BUILDINGPERMIT ISSUED---------------- ------------------------•-------_ -•---------------------------- DATE------- ------------------------------------=---------------- Alterations and/or recommendations:_---_------_-_-------------------- ` ------------------------------------------------------------------------------------------------------------------------------------------ -----------------•----------------------------------------------------•--- ---------- --- ------------------- a ----- ----------------•------------ ------------- -------- ------------------------------ ---------- -------------------•--- , - - J2 FINAL INSPECTION BY..---------- -. -------------------- -- -------------- .D to ------ ---- --- -. --r y• - 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 ES-9-2M Revised W-2100