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t � . APPLICATION FOR -SANITATION PERMIT Permit No. __,a..1 ... (Complete in Duplicate) Date Issued .V9Is5---- Applice-ion is hereby madetothe San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County O dinance No. 549. JOB ADDRESS AND LOGP.TION-----1--------�------�----- --T---- -- ----• ------------------- ----- Phone----- ------------------------------ Owner s Name.--- _- Contractors Name--- --- -- ------------------------------- -- ------------------------ ------•---------------•---- -------•-------- ------ Phone---------------------------c,------ Installation will serve: Residence F1 Apartment House El Commercial F] Trailer Court ❑ Motel [:] Other [f (%1+ l" Number of living units-_________ umber of bedrooms ________ Number of baths -------- Lot size Water Supply: Public system [Community system ❑- Private'❑" Depth to Water Table -------- ft.. Character of soil to a depth of 3 feet: SMand ' 7Gra ElS;ndy Loam o Clay Loam'❑ Clay [jL'�Adobe Hardpan ❑ Previous Application Made: Yes E] No 9 �New Construction: Yes No ❑ ..,0 4 � r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f ublic sewer is available within 200 feet) � � � " `77�`" ��-- L S/_ ------.Mater I Septic -ark: Distance from nearest well__' ________- -_ ista c� froom foundation__ _ ,j� ' e GrJ ------Liquid depth - ----C�'_--------Capacity No. of compartments------ 1z X q `d,,W'.,,� ) f Dis os Field: Distance from nearest we,L__' istance from foundation!_/�--�!"" Distance to nearest lot I'ne� __5 1 / Number. of lines----------- ._.. '0--------_vLength of each line_____________iJ ?1----,Width of trench.____'! --------(_.____.__.____ Type of filter materi -- Imo'----Depth of filter material------_J ------Total Ilength------------- - -- -----------------•- - . _____________Distance from foundation_-.-____.._.__:-___.Distance to nearest lot line----------------- Seepage Pit: Distance to nearest'wel!___^___ Size: Diameter---- ----Depth--------------------------------- ❑ Number of pits----------------------Lining material------------____-- ---- Cesspool: distance from nearest well_ ________- Distance from foundstion__________-_______.Lining material_____________________________________ 11 _Li Liquid Capacity __________gals. ❑ ----- -Depth q P Y Privy:; Size: sta Diameter. Distance nearest well--..--- ------------------------------Distance from nearest lauilcling----------------------------------------- .�..s.,,,.,..,w ••.. • .t1 _____________________ ❑ Distance-to nearest lot line-!--------------- - a---------------------- ------------------------------------------------ ------------------------------------- _ _______ - e_model'�ig and/or repairin (.da ri'be}:7_._...d•_.____---- ri�� - a __________________________________ •------------•------------------------------- _____________ _ __ -----------------------------------------.-________-.--_______.__________.-._____-___._____..._.___-.--_____________-._.____.-_____.______.____________________.___.____.-._____-__.______ 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)--- --- -- -- - ---------------------- --------------------------------- - (Owner and/or Contractor) 1 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 APPLICATIONACCEPTED BY--------------------------------------------------------------------------------------------- DATE REVIEWEDBY------------------ ------------ ,�----------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------- ....................................--------------- Alterations and/or recommendations------------------------------- -- --•--------•----•------------------------------•--- __j ;i------------------- ------------------------- ---- FINAL 'INSPECTION BY:______________________ ------ ----- 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 a ES--9-2M Revised W2100