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APPLICATION FOR SANITATION PERMIT Permit No.-_A-©.._'_'-d_./_"_ (Complete in Duplicafe) - 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 complia nce:.wif /Cgu ter Ordinance N . S49. r JOB ADDRESS A D LO TION-=- -- --------------------- _r�- � W797 Owner's Name______ _____ _"__ -- ---- ------ ------------- �- - - -- Phone---�-- ---Address------------ ._� �" -- - `, --------- Contractor's Name------- Installation will serve: Residence Apartment House ❑ Commercial - ------------------- --- - -- - - ------- -------- --------- --------- ----------- -- Phone----- ❑ TraiJe /Court ❑ Mofel ❑ Other ❑ Number of living units: __ _iNumber of bedrooms _`-� Number of baths 1 YL n Y `''- of size --_ - Water Supply: Public system � - - ---------�--" ------- -------- Community system ❑ Private ❑ Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: .Sand ❑ Gravel ❑ Sandy LoamClay Loam [] Clay El Adobe [Hardpan E]Previous Application Made: Yes 0 No 1 New Construction: Yes Q" LlNo TYPE OF INSTALLATION AND SPECIFICATIONS:- (No septic rank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___ Dista�e fro foul ation-__/Q . No. of compartments-___- _-_ i S __ ------- Materi 1 r ze Liquid depth -- Dispos Field: Distance from nearest well-___-"' " Capacity__11� " __-_Distance from foundation_ ___-; Distance to nearest lot Ii e_ o� Number of lines___ ______ __ Length of each line_______ aef----- """""" y� Width of trench__--__fu_--__ Type of filter material__ �_ 77 '3---- -- ! s>LDepth of filter mater;al--------- -At-------Total length--------- ----__----- 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-------.__--_-_-___-_ Priv Size: Diameter-----i---------- --------------------Depth--------------------- ----- ---------------------Liquid Capacity----------------------------gals. Y: Distance from nearest well_______.---_ x ____--____-Distance from nearest buildiri El Distance to nearest.lot line g ---------- ---------------- Remodeling and/or repairing (describe):______._-_-________ ----------------------------------------------- ----••---" t I --•-------------- - ere-------------------------------------------- a -----------------------------------------•------------------------------------------------------------------------------------------------------------ I hereby certify that I - ---have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, rules d:regulations of the Santioaquin Local Health District. Si Signed)-( 9 )- ' --- ---- - `-�'� ------------------------- (Plot-plan. BY: --------- -: (Owner a�n�/o�r Contrac - ---- --- - --(True}------- ---- showing size of lot location`of system jn relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY H APPLICATION ACCEPTED BY__4`�' ." DATE REVIEWED BY ---------------------------------------------- ------------------------------------- - ------------- ---------------------------------- ----------------- BUILDING PERMIT ISSUED-------------------'--------- :D.ATE ---------------------- " `5. aerations and/or recommendations:__ ________ ----------- .DATE - ------------------------ -------------•------------------ � - --------------------------------•------•------------------------------------ ' --- ---------------------------- --------------------------------- -------- -------------- - ---------------------- --= ----- ----•--------Dat------------------------- - FINAL ------- -------- --- - F1NAL INSPECTION BY:-_-____ ""-�_`_- - -" e - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North C Street Lodi, California Menteta, California Tracy, California ES-9-2M 8-51 Revised W-2104