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, r V APPLiCAT!®N FOR SANITATION PERMIT Permit No. .�-�.Kq_ � `Ui- (Complete in Duplicate) S 3 Date Issued --- Application 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. JOB ADDRESS AND LOCATION___.__f-- j___�--__ ----------------- I Owner's Name----------- ---------------- Phone----- -- — -- --- -r-- - - -- --- Address__.... - :; - --------------------------•---••----••---------...-------------------------------- { Contractor's Name---- --- -- --- -. ------- ------ --- -------- ---- •----------------------------- Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court E] Motel ❑ Other ❑ t Number of living units:._--- Number of bedrooms _3-- Number of baths _/___ Lot size _0----------------- Water Supply: Public system El / Community system ❑ Private - Depth to Water Table d ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobee Hardpan ❑ Previous Application Made: Yes ❑ NoK New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) z ' Septic Tank: Distance from nearest well_________________Distance from foundation-------------------.Material------------------------------------------------- ❑ No. of com artments--------------------------Size-----------------------------_-Li.-Liquid depth-------------------------_Ca Capacity P qP Y !� ' Dispos Field: Distance from nearest well_.A1_.____.Distarice from foundation__ __ _________ Q_ Distance to nearest lot line----_.,�--_-. OQ ?WrNumber of lines---__-3-.__.__-.___..__ __ Length of each line sX'-X r'� __.Width of trench-__ __ ---5/-�/____________ Type of filter material..��_ D-c __Depth of filter material--�S'!-__..__-Total length.-__.�/2 _0*----------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------- Distance to nearest lot line-----._.----_---_ ❑ Number of pits._------------------Lining material-----------------------Size: Diameter-----------------------Depth__._.._______._._____------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------------_.-_-- ❑ Size: Diameter---- -------------------------------- Depth---------------------------------- ----------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well----------_---------------------------------------Distance from nearest building--------_-._-.----___-__.-______-__-_-. ❑ Distance to nearest lof-line------------------------------------------------------------------------------------- ------------------------------------------------------ Remodeling and or repairing (describe):--_ --.---__-.-_ --- -.^--4-- ---------------------------------------------------.._.._..-•---- ----- --- ---------- ----,--------------------------- d _ Y -------------- - = _ .e__ _ --- _ ___ I hereby certify that l 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) O ner and/or Contractor --------=------------------------------------ ---- ----- ---- 13y--------------- � --------------------------{Title)- �- --------------------- (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY---------------------------------- -- -- - ---------------------------------------- DATE---------------- ------ REVIEWED BY--------------------------------------------- � Z.�-----�" ------------------------------------- --- ------------------------------------------------------- DATE- ----- ---------------- ----------------�--------- I BUILDING PERMIT ISSUED---------------------------------------------------------------------------------- Alterations and/or recommendations:------------------------------ -•---'------------------..-..-------------------------------------•--•----••-•--------------------------------------------- ----------------------- ----------------------------------------------•----- --- ------------------------------------------------ Date --------------------------------------- ( FINAL INSPECTION BY------------l------ --•- --------------------------------------- .. 4y 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-9-2MS 10.52 Revised W-2100