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r. APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) � Zp Date Issued T Application hereby made to theSan'Joaquin Local Health District for a permit to construct and install the work herein described. This applic tion is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION....---= CK_�on.�-----J. h`-c�ca4---------------------•--------------------•- Owner's Name----------------------------------4:44C ffl-N-----------4C ef'-0 _.--' ---- ---------------- Phone-------------------- --------------------•-----------•-------------------------------- Contractor's Name------- --------.- �d ��3--3-------------- C Phone------�`------"�----�-'7"--- Installation - ---- ` Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other SC-�7ao Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size --------14z •____ - "`-'--- Water Supply: Public system ❑ Community system ❑ Frivate ❑ Depth to Water Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay a Adobeo Hardpan ❑ ,6- Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No-❑ F TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-.S --------Distance from foundation_____w_.______-Material___ __ _____________-._____.______.---.---.____. f No. of compartments--------Z_..-_-------Size----- x- _X>_��` Liquid depth------�_`_�_---O-------..Capacity------.3 a S V t Disposal Field: Distance from nearest well---;.tea------Distance from foundation-_-'-'--'-.-....Distance to nearest lot -------�_____- Number of lines--------------'_ .--Length of each line--:------�-S-c3------.Width of trench----------------------------------- Type of filter material-?__-Depth of filter material----------l,:?........Total length____________________Ov ------------------ Seepage Pit: Distance to nearest well- -----------_--------Distance from foundation-------------------Distance to nearest lot line-___.______... 171. Number of pits----------------------Lining material----------.------------Size: Diameter---------------------- Depth-_------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- Si ❑ ze: Diameter--------------------- -----.Depth-.---------------- ----------------------------------Liquid Capac.i-fy-.--------------------------gals. Privy:. Distancerom nearest well _____ __________________________________Distance from nearest building ❑ Distance to nearest lot line---------------------------------------------- --------------------•-----•-------------------------------------------------------------- Remodelingand/or repairing (describe):-----------------------------------------•--------------••-----•----------•---•---------------- ------------------------------------------ -------- ---------------------------------- ----------------------------------------------------------------------------------------------------------•------------------------------ ---------------------------------- ---------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Statq11a , and rules and regul ions of the San Joaquin Local Health District. (Signed)..._.. -------------------------------------- ------------------------------- -----(Owner and/or,Contractor) By:------------ ----------- ---•---------=------ --------------- ---------------------------------- ------------------------(Tifle)------------------------------------ -------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT,USE ONLY APPLICATION ACCEPTED BY-------------- --- ---------------------------------------------- DATE----------�--- - REVIEWED BY.- ------------------------------------ ----------------- DATE BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE------------------------------------ ------------------------ Alterationsand/or recommendations------------------------------ --------------------------------------------`--------------------•-----------`----------•-----------•--` ...................`.. ------------------- ----------- -- -------- ------------------------------•- i..v` ---•-------•----•------------•----------- --- - - - - -- - ------------ ------------------------- -- --------- ---- -- -------------- -------------- 5 �� 1• FINAL INSPECTION BY:--------- -------------- ---------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--4-2M �0-52 Revised W-2100