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f�" ' APPLICATION FOR SANITATION PERMIT, ` Permit No. .__ _ _/_ __ tDoi Date(Complete in Duplicate} O `� I�s3u�ed Application is hereby made to the San Joaquin Local Health District for a permit to onstruct and install the work rein escrlbe /7 This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---_- Q+ --- l r- -----__��_ q_/ ------------------------ _� . " � Owner's Name---------------------------------------1 P., r j .------v i z,, \. Phone---�71.��I------ - --------------------------sK - Address- -------------------------------- r `_ ,J`) `` -:? y= 1 . jr ----•--- ---------------------------- Contractor's _3----- .q l Name............-•------------------------------- "�a. - ----- - ------------------------- --•- ._.-------- Phone--- !. .----� - ------ Installation will serve: Residence D�- Apartment House ❑ Commercial ❑ Trailer Court ❑t' fel ❑ Other ❑ 1 vin units: __I:__ Number of bedrooms _ Number of baths -r.-_- Lot size _ -- �.r �" � Number of living ` - -- ------ A-11 Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table J----- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No g-- 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 welL1-'__r__Distance from �•. _ ---- foundationfo�--.-----.Material-r-f Material--c'11146 r' 1 __________________ No. of compartments____.__`�_ _ - -Size � ._ _Liquid ---- ---Capacity s. Disposal Field: Distance from nearest ell- 4_____-Distance from foundation--/--$--'-----Distance to nearest lot line--- _ Number of lines--------- , �r ____Length of each line__e �'.1- __ Width of trench �" - --------------------- Type of filter material-------�_. _. f�_Depth of filter matsrial___..__�...... ------Total length__-. __ -----+----'-__,-________________ 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------------------. Lining material------------------------------------- F-1 __...__________--_.-____.______❑ Size: Diameter------------------ -- ----- ----------Depth_--------------------------------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well------- _________________________Distance from nearest building______.._____________.________.____....._. ❑ Distance to nearest lot line----------------------------------------------- ----------------------------------------------------------------------------------------- ---- Remodelingand/or repairing Idescribe):----------------------------------------------------------------------------------------------------------------------------------------- ----- - - -----------------------------------------------------------------------------------------------------------------------------------------------••---------•---------------------------------------------------------------- -----------------------------------t -------------•---------------------•-----------------------------------------------------------------------------------------------•------------------------------------------------- I hereby certify/A_ I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat Sand rules and regulations of the San Joaquin Local Health District. (Signed) � ° -- ---- :--- } __Owner and/or Contractor) a ---------------- By: ---------------- - '!�--------------(Title (Plot plan, showing size of lot, location of system in relation wells, buildAgs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------- --------------------------------- DATE----------- ��J REVIEWED BY-------------------- � �� '---�-/REVIEWED BY-------------------- ---------------------------------------------------------- ------- --- - --------------- -- --•--- DATE---- ------- -- --....----- - ------------------------------- BUILDINGPERMIT ISSUED---------- ------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------------- -------------------- --- ---- ------------------------------------------------------------------------------------------- ------------------ ---------------------------------------•------------•------•--•-----------------------------------------------------------------------------------------------•---•--•- -------- •----------------••---------•-------- -----•------------•--------------------------------------------------------------------------------------•-----------•--------------------------------------------------•---------------------- --.------------------------- -----•----------------------------------------•------------•---•-----------------------•-------•-------------------------------------------------------------------------------------•---------------------------------------- ----------------------------------------- •--------------•-------------------- --------------------------------------------------------------------------------------------------------------------------------------------- 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 ,�//,ZS-9-21A 10-52 Revised W-2100 —