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APPLICATION FOR SANITATION PERMIT Permit No, T_-----------. (Complete in Duplicate) Date Issued .f EZ..CcJ—,C " -5_r 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 6h County Ordinance No. 549. OP JOB ADDRESS AND LOCATION_ — - _ ne_" ------------ - �J ---- Owner's Name ------ Address--------- --- -------- - ----------------1 Contractor's Name-------------------- ---- ------ Phone. Installation wil[serve: Residence Z Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ---- Number of bedrooms __ � s�---x-�_-��-_-�------------"------"-- Number of living units: _I Number of baths .__�___ Lot size _____ _- Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table -.6-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction. Yes )d No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) mo�oo,,,� Septic Tank: Distance from nearest well-__I _ Distant fro f u tion ' b Mater'al G -- � '"---- -__--Size--- '_ _ --Liquid depth--------�_-----------Capacity__- --- No. of compartments__________ ___ Disposal Field: Distance from nearest welL_��----Distance from foundation---."0--------Distance to nearest lot I ne__S-t__` ; Number of lines_______. __________________Length of each line____-0--------------Width of trench...._.�i . __ ______________i ! Type of filter material ______---------.--------Depth of filter material--------------- -------- length---------------------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-----. -------- . ❑ Number of pits.---------------------Lining material-----------------------Size: Diameter Depth C Cesspool: Distance from nearest well-------_---------Distance from foundation--------------------Lining material----------------------------------- .. Size: Diameter------------------------------------ Depth---- --------------------------------------------- Liquid Capacity gals.} ❑ r ._____-_Distance from nearest building ---------------------- Privy: Distance from nearest well ---------------- - (/1 ; _.. Distance to nearest of Ine----------------------------------------------- 14A&--- ----- ------•------ -------------- ----------------- r Rem77 �elingandl orre ai i (describ ]:__ _�_-- `� _ BAR - ------------ ---- ------------- -------•-----------------•"---------••----- .----------------------------------------------------------------11 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin aunt ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ___----- ""--__-._____--____(Owner and/or Contractor) (Signed) - - -- ------ -- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). w FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- ------------------------------------------- ---------------------------•-•--------- DATE-------------------------� �------------------- DATE REVIEWED BY --------------------- �� -- ---- - BUILDING PERMIT ISSUED----------------------------------- DATE Alterations and/or recommendations:----------------------------- -" ------- c -------------------------------------------•----------- -- - - - --------- - - ------- ----------------- ------------------------ ----------------- ------------------- - --------- - - FINAL INSPECTION BY:-----_ ------ ---- ------- t�'�j —- ----- Date -r-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30o 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