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APPLICATION FOR SANITATION PERMIT Permit No. __ , -5 3,•. (Complete in Duplicate) �f Date Issued L--/ ____-___ 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 compliannc-e with County Ordinance No. 549. JOB ADDRESS AND LOCAT ONC�w� rc - ,y1.,,, _ .s�� Owner's Name------------------- --• ic ..------- ------------ - ------ hone----------- Address 1t �r ►!.t_ -- -------------------------------------- Contractor's Name --------------• ---------•--------•---------------------- Phone --------------- <,Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Q Tr p/" Number of living g units: _3-___ Number of bedrooms,3____ Number of baths .5____ Lot size _______________________________ ----------------------------- Water Supply: Public system E] Community system E] Private ❑ Depth to Water Table _._'`4.1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam K] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes 21""'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___50_`_._._Distance9, from foundation-_�0..........Material 40'19 G ----------------- ------ ® No. of compartments-------"I------------Sizer ---X- --------.Liquid depth--------�------------Capacity_./ 0-0---- Disposal Field: Distance from nearest well-.Q_r_- Distance from foundation__/d--___-_____.Distance to nearest lot line___s''!++. ® Number of lines---------3-- ' � _____________ Length of each line------- of trench.__-�.�--.- ------------------- Type of filter material ,,) _ _-_ Depth of filter material_____, ----__Total length--------- j/_________ ------------ 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-------------------- material_..___-_--_-.____._____- ---------- Size: Diameter--------------------------------------Depth-•---- --------------------------------------------Liquid Capacity----------------- ----------gals. Privy: Distance from nearest well_______________ -------------------------------------------------Distance from nearest building------.------------------------- - El Distance to nearest lot line.________________________ Remodeling and/or repairing (describe):--------------------------------------------- ----------------------------------------------------------------------•--••------•------- ----•--------------------------•-----------------------•---------•------------------------------------------ ----------------- F.1 -------- ------------------- --------------------------- -------------- ---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State I S. and rules and r ulations of the San Joaquin Local Health district. (Signed____________ __ __ __ •--�� ------------------------------__Owner and/or Contractor By:--------- ---- _------------- .-------- Title _ ______ - - - ---- --------- - -------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). DEP RTME T USE ONLY APPLICATION ACCEPTED $Y REVIEWED BY -- .�#-�' `�^-~------------------ DATE---�j"_% -- -- -------------- -------------------------------------------------------------- ------------------ -- DATE -- - --------------------------- UILDING PERMIT ISSUED---------------------------------------------------------------------------------------------- ---._ DATE.-------------•------------ Alterations and/or recommendations:--------------- -------------------------------------------------------------------------------------------------------------------------------- -------------------------- ----------------------•.--------•------•------------------------•--------------- --------------------------------------------•----------. ------•-------------------------------- ----------------------- . FINAL INSPECTION BY-------- --- --- - ------- - --- w_ 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 10-52 Revised W-2100