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APPLICATION FOR SANITATION PERMIT Permit No. ____. .__?_ __ (Complete in Duplicate) Date Issued ____7_�_3_�J- Application is hereby made to the San Joaquin Local Health District for a permit,to construct and install the work herein describbd. This application is made in compliance with County Ordinance Noa 49 A 1 :? E JOB ADDRESS AND LOC6N________ _-- �__ E ------------------------------------------------- Owner's Name__________________ f - - ---- - - ��'---- - --------------------------------------------- Phone------------------------------------ Address--------------------- _..r.' �= =- r I Contractors Name----,, f.�.z- _—e` ��--�' ` -------------------------------------------- Phone C1 r -- If Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _��unify er of bedrooms"_ Number of baths ---�__ Lot size _____t __ , ` U___________ Water Supply: Publics stems stem Private De th to Water Tabie ________ ft. pp Y� Y Y ❑ ❑ p Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [1]�rdpan ❑ 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.) " Septic Tank: Distance from nearest well-/v stance from foundation__A_______--Material- ./�"c�6�'' � No, of compartments---- ----- rr _ ____Liquid depth__s!:::�--_______________Capacity---Y- _____ Disposal/Field: Distance from near@st of-V_ Distance.from foundations , Distance to nearest lot. line--I- -- Number ine_�1- �l Number of lines___ _ '�_____ ___-- ,/ _ ._Length of each line__�^s�_ ______ ---- Width of trench------`�- Type of fitter mate 1al_ a,,;�d---?rDepth.of filter material___�,j1�""5_:-__Total length_____ ---U_____________ 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 we11----___________Distance from foundation--------------------Lining material____________________________.-___._ ❑ Size: Diameter----------------------------+---------Depth----------------------------------------------------Liquid Capacity---------------------------gals. r" Privy:' Distance from nearest well------- from nearest building__________________________________________ ❑ Distance to nearest lot line = --------------------------------------------------------------------------- Remodeling and/or repairing {describe: - �"`"----- -�----------------------�-•------- l ' -----------------------------------------•.--------------------------------- ------------------------•-------------- --------------------------••------------------------------ ---------------------------------- 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 rvles`l and regulations of the SanJoaquin Local Healt�Dis ,ict. -----C��, � (O ner an Contractor) (Signed) _ = BY• L -1 - --------------------------------------------------(Title)------- y :'7------------- (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 APPLICATION ACCEPTED BY----- -------------------------------I------------------ ---------------------------------------- DATE_- A REVIEWEDBY----------------------------------- ------- ---------------------------------- ------------------------------------------ DATE----- ------------------- BUILDING PERMIT ISSUED---•------------ --- ---------------------- DATE �`� - Alterations and/or recommendations: -------------------------------------------- _______________________________________________________________________._-____-_---_________________.._________._________________.____________________________.____-___.________________________________________________________ S FINAL INSPECTION BY: 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 •? ES-9-2M 8-51 Revised W-2100