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APPLICATION FOR SANITATION PERMIT Permit No. �. - (Complete in Duplicate) Date Issued '�- _S -..••fig Applies*ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Th Es application is made in compliance with County Ordinance No. 549. JOS ADDRESS AND LOCATION..___., -------- -----------•--------------------------------------------------------------------------------- _ _ Phone_ --/&K, Owners Name -------------•----------------------------- ----------- Address Contractor's Name____ -s--- Phone._ _` A---•'x-6• - ------- ---- - --`. --- Installa+ion will serve: Residence a?'-Apartmen# House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ d------------ -------- Number of living units: ._-- Number of bedrooms A_ Number of baths .---- Lot sue ____ --�-�--��-- - Water Supply: Public system ❑ Community system ❑ Private Ej-15epth to Water Table/4--,ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R—Hardpan ❑ Previous Application Made: Yes ❑ No-5U.,-New Construction: Yeso ❑ ' °~°-~ TYPE OF INSTALLATION AND SPECIFICATIONS: '(No septic tank or cesspool permitted if public sewer is available within 200 feet.) I . ..� s -ec. �t-I G k Septic T k: Distance from'neare_st well___�D-___-pistance from foundation___________-_._ _.Materia---_-_._r________ ________________________------- Septic .2 S __ yDq depth' Capacity._Aa�/(/ No. of compartments Size Liquid de th `5 ---------- � n t k ` Disposal d: Distance from nearelst well_-yAti•_---Distance from foundation__�ir?9__ y'.Wiclt ---------- Distance #t nearest lot li __` _..________ Number of lines----------- --* ----------Length of each line--�f4-_------.�a----Width of trench-----a-`�---------------------- r-� ---Total leng#h_----Z-•-a-�--------------------•-- Type of filter material__!&_!'f-b t--Depth of filter material --_____- Seepage Pit: Distance to nearest well-_____________________Distance from foundation--------��------Distance to nearest lot line--------------- 1 ❑ Number of pits---------------- Lining material-----------------------Size: Diame er 7-------- ;------,Depth--------------------------------• r Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining'material__..___...___.____-.___________-____. ❑ Size: Diameter------------- --------._Liquid Capacity----•-----------------------gals. ----^-'-•---- ----- --.Depth- -------------------------=- ---------- J Privy: t -----------------------------Distance from nearest building_-.---------------------------------------- ` ET Distance from nearest wel�_________________ _ 1, Distance to nearest lot line---------- -------------------------------------------- •------------------------------------------- Remodeling and/or repairing (describe):----------.--'•- --------------- -------•------------------------ `-------------------#--------•---- = .. -- `- - -----•------------------ i- _____________________________ C rw. �... �.. ��... ___________________________________________________________________#___________.._._____-_____________________--____. __________________________________________________________________________________________________________________________c-_-___.__-___._____.--_________--_______-_-___...-_.____________________.______... I hereby certify that I have+prepared this application.and +hat the"'k will be done in accordance with San Joaquin County + ordinances, State laws, and rules and regulations-of,the-Sad.Joaquin Local..Health.Distriict_� ------------------ --------•---- (o fie- and/or Contract (Signed)------- ---- ------r---- --- o-) -- L/N/J Bl � --------------------------------------------- (Plot ------------------------{Ti+1e) (Plot plan, showing size 6f lot, location of system ielation Jo-wells,,buildings, etc.,•can.be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -------------------------------------------------V-s--� -------------------------------- DATE------ �1 r f� " �----------------- REVIEWEDBY------------------------------------- DATE------------------------------------------------------------ IBUILDING PERMIT ISSUED-------------------------------------------------------------••----------------- ------ DATE---------------------------- Alteraiions and/or recommendations--------------------- ------------------•---------------------------...______ ------------------•--------- ------ ---------------------------------------------------- ------------ ________________________________ __._..--_._.---_.____.____.--__.____-__--_ ------ 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 H-9-2M Revised W-2100