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IT..1.lw� __ � S-1)_4 --------%% rl f- APPLICATION FOR SANITATION PERMIT Permi o. ...... -- � " (Complete in Duplicate) 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. JOB ADDRESS AND LOCATION.. _ _- .�_ --------------------------------------------------------------------------- Owner's Name----- ------------------------ --=------------ Phone----•---- ---•---------------------- Address !� ---------- Contractor's Name---- 1.t1 11-` 'i `--4------- ---------------------------- -------------- Phone Installation will serve: Residence ❑i Apartment House ❑ Commercial Trailer Court=[] Motel ❑ Other ❑ Number-of living units: "_.___ Number of bedrooms ______.- Number of baths _-_____ Lot size __-1_ ___"" -- -.Q-------------- Water Supply: Public system ❑ Community system ❑ PrivateV Depth to Water Table -------- ft. Character of soil to a"depth of 3 feet:: Sand ❑� Gravel ❑ Sandy Loam ❑ Clay Loam-E] Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) U. Septic Tank: Distance from nearesr well�B._._____Distance from foundation--_I_�_____.__Materiai___ cti IRNo, of compartments------------------Size__1Y_. ``r---- ---Liquid depth Disposal Field: Distance from nearest well--sS�-__.._Distance from foundation_____�-0--------Distance to nearest lot line____1;7_".---- i Number of lines of -----------Length of each line------1-t�--c�-------------Width of trench.---�------------------------- Type of filter material. _ �rth of filter material___! �_.ry"-------.dotal length------I.D__p------------------"""-•- k " Seepage Pit:. Distance to nearest well.._.__`______________Distance from foundation___--______--____--Disfance to nearest lot line------------------ ❑ Number of pits----------------------Lining matsrEai-----------------------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.-____-.._-„ a or re airin descrsbe :_ ."" ------ f��`-�----- "" " ' '` """"" Remodeling d �! / repairing � I� - --- , -----------------------------' ------------ ---- ------- ---------------------------------------------- ---------------------- ---------------------------- ' --------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- i 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] i - (o t ------------------------------------------------------------ ' � ___---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.---<:D;_-- ---------------------------------------- REVIEWEDBY------------------------------------- ---- --------- -------- --------------------------------------------- DATE------- (;--------- --------------------------•------- BUILDdNG PERMIT ISSUED----------------------- ------ DATE ~ ------------ 3 Alterations and/or recommendations-------------- ---•--------------------•-------•------------------- -----------•--•----------- .� -------------------------------------------------------------- ------------------- •----------•--------------•------------•------------------- ---•-----------------------• , ------- ------------- -------------------- -------------- -----"--- -------- ---------------------- .- ti - `� 'FINAL INSPECTION BY:-------. /U ---------------"----"------ 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 I ES-9-2M Revised W-2100