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APPLICATION FOR SANITATION PERMIT Permit No. .._Gl___�.__.. (Complete in Duplicate) yL Date Issued ____-- -,/ Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the Gvork herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------ - "---1I�-- - --------------------------------- ----- -. ! ------------------_-- Owner's Y Owner's Name------- 7 --_ �, Address ---------------- Contractor's Name--------- cam. r -------------------- -•-f---------------------------------------------------------------------------------------------- ...__ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial [ti'-frailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ' �_____________ Water'Supply: Public system ❑ Community system El Private Depth to Water Table 0_2-ff.- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam �ay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [�New Construction: Yes Y�'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r , Septic Tank: Distance from nearest well_____-? _.__Distance from foundation____ _U--____.Matpri9l_____ __h___o__1,. ---.__`�_____- [ No. of compartments---_------2-----------Size--------------------------- ---Liquid depth-------�f__�_'----------------Capacity---- ?----_, Disposal Field: Distance from nearest well �7 --_Distance from foundation_____- _ __.--Distance to nearest lot line----- j --------- EK, __ -- [ Number of lines__________ _____ r�__-_____-��_Length of each line______,�.. �__.Width of trench------�____�_____________- Type of filter material_/_47-`__Z____Depth of filter material---LS_-----------Total length_______--_1____ _-- 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 weft_________________Distance from foundation--------------- -- Lining material------------------------------------- - ❑__ TF-- ,-Size: Diameter" __ - _ r� r __ �Liquid Capacity---------------- ----- 7- -gals.-Privy: Distance from nearest well-------------------------------------=-----------Distance from nearest building----------------------------------------- Distance -_--- -_---- --------------------------- Distance to nearest lot line--------------------------------------------------------•-------••-------------------------------•-- Remodelingand/or repairing.(descrsbe)---------------------------------------------------------------------------------------------------------------------------------------------- �. -------------------------------------------------- ---------------------------•------------------------------------------------------•-•----------------------------------------------•------------------------------ 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. � T - (Signed)-------1 v �1�------------------------------------------------•-------••---- -- ------•------------------ -(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 9 REVIEWED BY ---------- -- ---- -------------------------- ----------------------------------------------- DATE BUILDING PERMIT ISSUED---------------------------------------• ------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------- --------- ------------------------------------------------------------------------------••-•-------------•------------- -----------------------------•----------------------•-----•-----------------------------------------------------------------------------•---------------------•----- _..-------------------.--------------------•---•------ •------------------------------------------------------------------------------------ -------------------....--- -----------------•-------------- ------------------------------•-------------------------- ------ ---•--------- ------- --------------. --------- FINAL INSPECTIO - ---------:-------------------------- Date.---------- SAN JOAQUIN LOCAL HEALTH ISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 4 E5-9-2M ; Revised W-2100