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APPLICATION FOR SANITATION PERMIT Permit No.-J .4_- ___-- (Complete in Duplicate) 0/ /3 Date 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 County Ordinance No. 549. ) JOBADDRESS AND If AT?N..- ----------------3----------w------- --------------_--- -- ----------••---------------------------------------•------------ Owner's Name---------- -- = ---- Phone f� ��✓ --- --------------------------- --------------------- ------ Address V �1� ---- p. 7 Contractor's Name----------- ---- ----- -------------------- k ------ Phone�_.C2 _7 g/-- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size _________--_G I Water Supply: Public'system E] CoM'munity system E] Private [Depth to Water Table�Q ft. Character of soil to a!depth of 3 feet: .Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ 1 ! Previous Application Made: Yes ❑ No New Construction: 'Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation______..___.____.Material--________ _---_______.._._ ❑". No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- i Disposal Field: Distance from nearest well Distance from foundation--------------------Distance to nearest lot line_________.___--_ ❑ Number of lines-----------------------------------Length of each line------------------ _-- Width of trench-----:-------------------------.--- Type of filter material__________________ ___Depth of filter material-----------------------Total length_------------------------------------------- Seepage_N, : Distance to nearest well___ ______________Distance�ro,�ti un tion_____A_.2.___..Diisstpaance to nearest lot line-- __________.__ [ Nur"nber of pits--------�___.-------Lining material______--CC-- .__�Siize: Diameter.___-✓ 4Depth------S� r-------____-• 1 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_.____.__________-_-._--__________- ❑ Size: Diameter--------------------------------------Depth---------------------------------- -----------------Liquid Capacity- ------------- ------------gals. t ! 5 Privy: r Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line-------------------------------------------------- Remo eling nd/or r�Fairing/describe):____ __-e-4 _ ---------------- -•----- � - - ------------------------------.------•--t-------•---••-----------------•----------------•-••--------------------------------•--------------------.....------ ------------------------------------------------------------------ ------------------------------------- - ------------------------------ ---------------------------------------------------------------------•--------------------------------------------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stateglapand rules and regul ions of the San Joaquin Local Health District. Si ned r and/or Contractor] g )---- #gy:------------ ---------------------------------------------------------- --- ----------------------------------------(Title)------ --------------- (Plot plan, showing size'of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------------- DATE----- -------- REVIEWED BY------------------- t - - ------ DATE = A ------- --------------------------------- DATE PERMITISSUED---------- -------------------------------------------------------------------------- ---------------- DATE------------------------------------------------------------ Alterations and/or recommendations----------- ----------------------------------------------------------------•---------------- -------------------------------------------------------------------------------•--------------------------------------------------------------------•--...------------------------•-------------------------...------ A . ----------_--------------------------------------------------------------------------.------------------------------------------------------------------------.--------------------------------------------------------------- ---------------------------------------------- T __ _._ j FINAL INSPECTION BY:-_____.._ _�&---- w ____------- Date---- '- e7__.'' 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 c,