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APPLICATION FOR SANITATION PERMIT Permit No. _--.Ia?4---- (Complete in, Duplicate) Date Issued �I----------- --- 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 Ord' ante No. 549, JOB ADDRESS AND LOCATION--------- .Owner's Name------�--------- - ----- ---•- ----- -------------- ------------------•---•------ -------------------------------------------- Phone------------ ........... Address_ �1 -�r 9 Contractor's Name---------- ----------------- ----------- ------------------------------- -------•---•------------------------------- Phone.----- •----•------------ ------ Installation will serve: ResiclenceW Apartment House ❑ Commercial ❑ Trailer Court ❑ �lotel E] Other ❑ Number of living units: --- Number of bedrooms --"7<Number of baths -_-I---- Lot size _--_--- -- - =_-_-------_--_-__-___--_ Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table -S74.dl ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑� Clay ❑ Adobe-& Hardpan ❑ Previous Application Made: Yes ❑ NoX New Construction: Yes ❑ No ? !' TYPE OF INSTALLATION AND SPECIFICATIONS: q (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank` ante from nearest well-----------------Distance from foundation-------------------Materia)------------------------ Sept 1 of compartments -- ------- —Sze Liquid depth------------------------ Capacity----------------------- Dis osal Field�� 'sance from nearest wel _. :----- %-- e rom oundation--_ p �� !Q-�1- ------Distance fo nearest lot umber of lines----_- -- ---__. Lengfh of each line___-„6.5 Width of trench.-- <- �r - [�" Type of filter tmaterial-_ -)-/ ', -Depth of filter material--- ----.--Total length------- -. Q__ --- .- 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 lot line---------------------------------------------------------- � 17 Re odan eling d/or repairing (describe):---- ._ __ 4 �� ---- �----------•------------------- ------------- ()------- ------------------------------------------------------------ --------------- ------------------------------------•--------•-------- ---------------------------------•-------------- -------------------- ------------------------------- -------------------------- ---------- ------- ---------•-------------------------------------••------- ---•----------------••------------------------------- -------------------------•----------------------------------- 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 a d regulations of the San Joaquin Local Health District. �7'G��/I (signed)---- .-- ------------------------Z---- - •- - ------------ ------------------ - ------------------------------------------------ --------(Owner and/or Contractor]-------------------`-- ;----------- f----------- - - -------------------------------------------------------(Title)--------------------------------------- ------------------------ (Plot plan, showing size of lot, lot ion of system in relation to wells, buildings, etc., can be placed on reverse side). I r FOR DEPARTMENT USE ONLY �. APPLICATION ACCEPTED BY-------------------------- ----- ---------------------------------------------------------- DATE--------------------------------------- REVIEWEDBY -- -------------- --- --- ----- - - -------------------------- DATE----- ------------------ BUILDING ✓ 1I -- ---- PERMIT ISSUED ------- _ ----------------------- DATE-----------I------------ --------------- Alterations and/or recommendations ----------------------------------------------- ------------------------------••--------------------- ---------------------------------------------------------------------------------------------------------------------------------------- •------------------------- FINAL INSPECTION BY-- - -------- ---- - -_�.�- C.--- Date-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2Ni`i6-52 Revised W-2100