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� CCy�r rr�� ' APPLICATION FOR SANITATION PERMIT Permit No. __--[___71-.------- (Complete in Duplicate) 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. - ------ JOB ADDRESS AND LOCATION-•-- - "mo- i------------------------------------------------------------------- -----f��_�I �C - f�1, �-'----- --- -- - "r- ---------- - Owner's Name.---? = o� F!'�"- - ---- Phone ----------------------------------------- Contractor's Name-----I./- —Z- rl_) ------------------------------- Phone-------------------------------•--- installation will-serve:, Residence: Apartment House ❑ Commercial ❑: Trailer,Court- ❑ Other ❑ Number of living units: ._ Number of bedrooms �--- Number of baths ___/_ Lot size .__ Q____- ---- - - - - 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 ❑ New Construction: Yes ❑ No ❑ §Ix TYPE OF INSTALLATION AND SPECIFICATIONS: -IQ (No septic tank or cesspool permitted if public sewer is available within 260 feet.) Septic Tank: Distance from nearest well----' ---------Distance from foundation-----0---------Material----------------------- _________________________ pr No. of of compartments---- .)- -----------Size--- < s Liquid depth ------------ Capacity----4?0V_ Disposal l Field: Distance from nearest well-----'--------Distance from foundation___-.0___-Distance to nearest lot'line_/d-------- Number of lines-------------- ---------------- --Length of each line-------/_--�Z?-----------Width of trench---jl-"�y-------------------- r 1+l e . Type o filter materiaV�i-__-__lit. �-Depth of filter matenal_____�_S�____-_-____dotal length________l -(]_______________._-__ 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------------------------------------- ❑ Si.. .. Depth t,h- " LiquidCapacity apa.ta.i+y � _ gals. . . ze: -- -- - --------- Privy: Distance from nearest well------------------------------------------------:-Distance from near building ❑ Distance to nearest tot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):--.--------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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. (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 fl " ------ DATE C. APPLICATION ACCEPTED BY-------------- � v _ ! REVIEWEDBY------------------------- ---------------- ----------- ---------------------------------------------------------------- -- DATE BUILDING`PERMJT�.ISSUED„-- = DATE -------- Alterations and/or recommendation ------------ ------ ' �� - --------- - ---- - ------- - - -- ----------- -- - ------- ------------------•-------------------------------------------------- - ------- ----------------- ------------------------- -----r------ ------- --------- --'-----V ----------------------------------------------------------- FINAL INSPECTION BY:.__O !_ --------------------------------- Date---------- ------------------------------- SAN ------ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street y 132 Sycamore Street 814'North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California 1 } ES-9-21VI 8-51 Revised W-2$00 t