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I� APPLICATION FOR SANITATION PERMIT Permit No. Jv (Complete in Duplicate) Date Issued Application is areby made to the San Joaquin Local Health District for a permit to co struct and install the work herein described. application is made This in compliance with County Ordinance No. 549. �J, 9 n_(.97 ``. JOB ADDRESS AND LOCATIQON__o.�' n --- ---- -- - --. `' C�,.�` r`'�` Z Owner's Name----!fl# P-------- l["- --;------•------ -------------------------------------------------------------- Phone-------- Address....... d F-- ---------- / _,7_4------------ ------------- - �- .- . / 'T Contractor's Name. r'"-~-----------------•---- Phone Installation will serve: Residence .Apartment House❑ Commercial ❑ Trailer Court [I Motel ❑ Other ❑ i Number of living units: ---L_ Number of bedrooms _3". Number of baths ,, ._ Lot size ____/_, __ .....-......... ------------ Water Supply: Public system [4 Community system ❑ Private'kDepth to Water Table .fir-Q ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [:] Clay Loam A-- Clay ❑ Adobe ❑ Hardpan ❑ 7 Previous Application Made: Yes ❑ No Ei— New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ^� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -- Z Septic Tank:, Distance from nearest well_______ _$______Distance from foundation___________________Material------------------ ____-_____--_-_----- � No, of compartments---------=------_------ Size-------------- -- - - -- -Liquid depth---------- -------------- Capaccty----------------------- Dispsal Field: Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line_______.-___-__- f,,..0 Number of lines----------------- -----------------Length of each line--------------- --------------Width oftrench ------------------- ------ G Type of filter material-------------------------Depth of filter material-----------------------Total len th________-_________-___-__-__-��- -/..Distance to nearest lot line_--_- Seepage Pit: Distance to nearest well-_451-0______Distance from foundation_________ ____ Number of pits.-----�-------Lining maferial__�� Size: Diameter--- --------------- Cesspool: Distance from.nearest weil----------------- o _ _ Distance from fundation____________________Lining material__-_------__--.-________ _-__-___ _. ❑. Size: Diameter----------------- -------�-----------Depth------ -----------; Liquid Capacity gals. . Privy: Distancefrom'nearest weal---------------------------------------_---------Distance from nearest building-------------------------------.---------- . ❑ Distance to nearest lot line- -------------------------------------------------------------------------------------- -------------------------------- ---- -- ---------- a Remodeling and/or repairing (describe):-------------------------------------------- ------- ------------------------------------------------ 3:----------------------------- ---------------•••---------.......__------------------•---------------•••--------•-----------------••------- ------------------------------------------•------------------------------------------------------------------- ----------------------------------=---------------------=---•------------------------------------------------------------------------•------------------------------------------------------------------------------------ ------------------------------------- ----------------•--------•----------------------•----------------------------------------------------.------------------------------------------------------------- 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)- ` 1 --✓ ' 13 --1--------------------------------------------- -- -'(Gkaner'e d7fim-Contractor) By� --. :.• t... ��•"°�^' "rr"" --------------------------------------------------------------(Title)--: (Plot pian, 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__ DATE - j ----------------- ----------------------------- --- ------------ REVIEWEDBY--------------------------------- ---------------------------------------•-------------------------- ------------- DATE-----A----------------------------------------- ----- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------- ---------- DATE------ •- --------------------•-------- Alterationsand/or recommendations------------------------ -------------------------------------------•-----------•--- -------------•---------_........---•-------------------------------------•- ---------------------------------------------------•--------- ----------------=-------------------- -----------•---------------------------•------------------------------------------------------------------------------- ------------------•--------•------------------------- --------------------------------- ----------•------- ------------------------------------------------------------- ----•-------------------------------------------•--- -------------------------------------------------------------- ------- - ----•---- ------ ----------------------------------------------------------------------------------------------------------------------------------- - FINAL INSPECTION BY:_ -- /GT1- ---- ------------- Date ---------el------ -------E- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streot 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 . - 1