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APPLICATION FOR SANITATION PERMIT Permit No. _. __ -G1-- (Complete in Duplicate) S 3 Date Issued -1 -S'I 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 coplianceth County Ordi�na�nncejNo. 549. , JOB ADDRESS AND LOCATE N___µ- -LL__ Owner's Name------------------ r- Phone --- Address .-•--••---------------•--.....••---•-• --------•------------------------------------------------------ -------------------------------------------------------------- Contractor's Name------------r--------- ----------- ........ --- ----•--- Phone--------------------------------- Installation will serve: Residence DT--Apartment House ❑ Commercial ❑ Trailer Court [j/,Motel E] Other ❑� Number of living units: -__!1-_- Number o rooms.---. Number of baths J---- Lot size --- :___.. _(�_ , _ ___ ---------- 1 A Water Supply: Public system ommunity system ElPrivate E] Depth to Water Table :--. - ft. x Character of soil to a depth of 3 feet: Sand F] Gravel E] Sandy Loam ❑ Clay Loam ]Clay ❑ Adobei' arc Th-o- Previous Application Made: Yes ❑ No New Construction: Yes TYPE OF INSTALLATION AND SPE CIFICA DONS: LL� (No septic tank or cesspool permi+t.ed if public sewer is available within 200 feet.) p k: Distance from nearest weir.-A&A -0istance from foundatip___ �(�____„_ Mat rill___ _ --------------- ,p ____ Septic Tan No. of compartments--_-�._— ___.._Size-_-_ -- ?Liquid dth_____ .!__..--------Capacity____ Disposal Field: Distance from nearest well__� _ stance from foundat' n......./0' ` Distance to nearest lot line__*-. Number of lines_ _._ Length of each line-15-4 '._..Width of french___--_- e Type of filter mate�ial--- ..Depth of filter material_-__-_ ��---.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-------_.--.------.--__-_-_--_---_--_ ] Size: Diameter-------------------------- -----------Depth-------:------------- ---------- ------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------'_-----___._-_-__--__-_Distance from nearest building-------.--------------------------------_. El Distance to nearest lot line-------- ---------------- -----------------------------—----------------- ----------------------------�---------------------------- Remodelinig and/or repairingR(describ--e)___ _-- -------- ------------- ---..-•----------------------------------------- ---- - --- ------ ----- ------- ------- ---------- t I ----------------------------------------------•--- ----•-•--•-------------------------------------------------------------------------------------------------------------•--------------------------------- -------------- I hereby certify that I have prepared this application andithat 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) Ie7 6y:1----- ---------------------------------------------------------------------------------------------(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 d `-?0001K----------------- ---------------- DATE------ - --r----"�T-------- ;------------ REVIEWEDBY----------------------------------- ----------•------------------------------------------------------------------------------ DATE---------------------.••.----------------------------------- BUILDINGPERMIT ISSUED---------------------------- ------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:.--------------------------------------------- ------------------------------•- -•---------------------------------------------------------------•--....... •. -------------------------------•---------------•- --•--------•---------------------------------------------------------------------------•--...-----------------------------------------------------......................1. -------------------•--- ------------------------------•••---------------------------------------------------------------------- -------------------------------------------------------------------------------------------- i -----•---------------------------------------------------------------------------------•--------r-------------------------------------------------------------------------------------------------------- ----------------- I ----------------------- ------ ----------------------------------------------------------------- -------------------------------------------------------------------5------�------------------------------------ FINAL INSPECTION BY:.. Date. --- 2 l SAN JOAQUIN LOCAL HEALTH DISTRICT } 130 South American Street 300 West Oak Street ` -32 Sycamore Street 814 North-"C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Io-52 Revised W-2100 t