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r r APPLICATION FOR SANITATION PERMIT Permit No. -_ ---�J-_ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Lccaf Health District for a permit to construct and install the work herein described. This application is made in compliance }with County Ordinance No. 549, i �,,�}� �l JOB ADDRESS AND LOCATION. E`_v-c V- 4 J = `" "=` R" s ---- Owner's Name------- _•__ r 5Z S � e P— 6 7 — � i - --1-__--- ---- �=-------- ---- c ------- Phone--------------------•--------------- Address----------- - --�.------ --•--'-------- ---Y---------�--�-�---- ��---�-------�----- ------- A Contractor's Name-_-___._�-_-e___,_-__- -____ Phone----------------------------------- Installation ___________________________ ___ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ e 1 e`�vr Number of living units: -------- Nu ber of bedrooms __Z Number of baths __J___ Lot size _ -- ______ ___________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet.: Sand ❑ .Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No �w Construction: Yes ❑ No l TYPE OF INSTALLATION AND SPECIFICATIONS: . 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest,welL_______________Distance from foundation--------------------Material----------------------------------------------- ❑ No. of compartments------ -------------- ---Size----'----------*------j----Liquid depth--------------------------Capacity----------------------- Disposal ------------- ---- p est weil.�-^`.-_.__.,Distance from foundation__)__-----_--__Distance to nearest lot line---- ---------i fh — -.Width 01 Dis osal Fie Distance from near _-'- --___---__ _�__-__Length of each line__________________________ __Width of trench______-- Number of fines-_�� Type of filter material5�r,t,_,__��___ti__-_Depth of filter material-_-__ !`_f______jTotal length------------------1a r___ Seepage �' Distance to nearest well____ `_____-__-__Distance from foundaI n•-------._ -------.Dist nfe to nearest to lipe___ ____ Number of pit,-------1------------Lining mate ria t� fi e: iamet er-----------------,Depth------ -----------------------� t Cesspool: Distance from nearest well____-________-_Distar .e from foundation-------------__-- '.Lining material------------------------------------- 0s) ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well------------------------------r------------------Distance from nearest building-__-_---__-___.._-_.-_-_-_______---__-__-. ❑ Distance to nearest lot line--------------------------------------- 0 Remodeling $nd/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------•--•-•-----------•--- f _____________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________ ________________________________________________________________-_-____-___-________.._-___-_---__---_-_____--.--_--________---____________-____-_-_-----___-_-.____.___-------- 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. D ' (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). FOR DEPARTMENT USE ONLY APPLICATION•ACCEPTED BY------------- ------- --------- DATE------------- - -- REVIEWED BY--------------------------------------------•-- f DATE BUILDINGPERMIT ISSUED--------------------------- - ----------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------- --------------- `------------------------------------------------------------------------------•---------------------------------- --------------------------------------------------------------------------------- --------•---------------- -----------------------------------------------------------------------------------------------------•---------- i ____________________________________ ____________________________________________ k------------------------I---------,--------------------------------------------------------------------------------- --------------------------------------------------------------------------__________________________________._--__.---__-______.________-_--_____________________--____--__-----_-___-__-___----_--______________-----___-__ _______________________________________________________________ FINAL INSPECTION ------------ Date_--YC--_-�0---- ---- 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 1 i —�