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APPLICATION FOR SANITATION PERMIT Permit No.4-_____te_ (Complete in Duplicate) l0/ I Date Issued 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 compliance with County Ordinance No. 549. ,,,,��. t-� ---- ---------4__*-------- ------------------------------------ JOB ADDRESS AND LOC IONl'`_01_�S.______ .- - L- /`*� ---- - Owner's Name------••----- rr41 -� "�� rE Phone------------------------------------ t AddressJ------- • C _ ---------•------------------------------------•-•---•--------------------------------- Contractor's Name----------------- -------------------------------------------------- ----------------------•----------- ------------------------------------ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House PS Commercial ❑ Trailer. Court ❑ -,Motel ❑ Other ❑ � Number of living units: -_ Number of bedrooms 3r Number of baths V - -� Lot size �Xl_,) ___ ---go- lk__ 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 K New Construction: Yes K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet � �+r►+._Material---- 1C�---- ------- Septic Tank: Distance from nearest well__ --Distance from foundation_,l__ -- _ No. of compartments-------'�_ -------_----Size-------------------.--------....Liquid depth--------------------------Capacity... '- ---� i Disposal Field: Distance from nearest eEl___`__._.-Distance from foundation_:/ _'7s+ D' �Re to nearest lot lir�___3___'s' Number of lines_______._ __._ ___ __. ___Length of each line,�4�o-45 �, __. tdth of trench.___3-tg�____________________ Type of filter material__c5i_ _ _ De th of filter material_. -_- �j_ Total length___7..r ________________________ P --{ ----- NkIn- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line----------------- ElNumber of pits----------------------Lining material-----------------------Size: Diameter---------_------------Depth_------------------------------ Cesspool: Distance from nearest well----------_------Distance from foundation___.- -------------Lining material__.__________________---------__.___.W ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well ________--------- ----------.---------------------Distance from nearest building_____...______._---_-____________.__..._. ❑ Distance to nearest lot line---------------------- ----•--------------------------------- ---------------------- ,-.-- --- ---------------�--f"-�-� ------------------ ----- ILA Remodeling and/or re airing (describe):r------------------------•------. ----------A--------------------------------------------------- -------- -------------------------------------------------------------------------------•-••------------------------------------------------=--•--------------'---- ------------- -------- ------------------------ I -- ----- ----I -- - hereby certify that I have prepared this application and that the work will bePorre•in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health Dr1c4. -- (Signed)-------------- --- _-----------------------------------------------------------------(Owner and/or Contractor) By:---•----------------=------ ? -----------------------------•--------------------------------(Title)--------------------------------------------- - --------------- (Plot plan, showing size of lolocation of system in relation to wells, buildings, etc., can be placed on reverse side). .ART ENT U ONLY APPLICATION ACCEPTED BY ----------- DATE- 1 *� REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------------------•-•------------ BUILDINGPERMIT ISSUED----------------------------------------------- --------•--------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------ -=----------------------• -------------------•------------------------------------------------------------•--------------------- ----------------- -- ---- -•--- - • - / ItAy- i- --- ------------------------------------------ -- 9r�t fff - --- ------ ------•------------------------- -----------------------------------------------vh ✓ ----------------------------- FINALINSPECTION 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 ES-9-2M 10-52 Revised W-2100