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APPLICATION FOR SANITATION PERMIT Permit No. ... _..�':3.J.- (Complete in Duplicate) �rG --------- Application 10 /� 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.E - -- ---------------------- JOB ADDRESS AND LOCATION-_ ' " - -------------------------------------------- ' Y1 Y ----- ,�-------------- -- --- Owner s Name__________M. II .. -I _ -f � -------------- ••-----•-- ---------• ------------•----------------------------•- ----- Address .:_x._. .. Contractor's Name-------------- • ^ Phone------------------------------ - Installation will serve: Residence partment House [ICommercial ❑ Trailer Court ❑ Motel ❑ Other E] ` Number of living units: J---- Number of bedrooms _- .'%mber of baths _�____. Lot size ____ 1 - --�4 = Water Supply: Public system ❑ Community system ❑ Private 1K Depth to Water Table __. ____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er Hardpan ❑ Previous Application Made: Yes ❑ No FV New Construction: Yes Ix 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 well__ ._ �- Distance from o da�."ion----- __d_-____.Myat�riaL____________________________�r� .-- No. of compartments------- ------ ----Size---- Liquid depth-------(..:......... ...Capacity---�f--44 p f lines___._----- '- (--- ,�.-0-- -----Width of tre __. nch_- ------ ------ Dis osal Field: Dl stanner o ce from nearest well /b-----•---Length of each line______�----Distance from foundation_._._ - --------Distance to nearest lot line___ Type of filter material_________________________Depth of filter material--------------.--------Total length------------------.---------------.------- C Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______._________ ❑ Number of pits--- ------------------Lining material----------------------.Size: Diameter-----------------------Depth-- ------------------------ --hh- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining materia l___.______--____-____---------_-` ❑ Size: Diameter---- --------- ----------Depth---------------------•--- ------------------------L•iquid Capacity----------------------------gal Privy: Distance from nearest well __---------------------- ---------------------Distance from nearest building.----____..___________---------------.-: ❑ Distance to nearest lot line--------- ---------------------------------------f-- ----------------------- ------- s�.+f,, ' � �''��' '�-------------------------------------------•------\.- +e Remodeling and/or repairing (describe):----- Q* --- J ----------------------------------------------------------------------------------------------------------------- -----•------------------•-------------------------------•-------------------------------�) ---------------------•---------- -----------------------------------------------------------------•--------------------------•-------•---------------------------------------------------•--•--------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Co ordinances,��S''tjja��te laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ----- _I! ...' (Owner and/or Contractor) ------ 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 APPLICATIONACCEPTED BY------------------------------------------------------------------------ ------------------------ DATE-------------------- --- DATE .r "' ------------- REVIEWEDBY-------------------------------------------------------------------------— �---- BUILDING PERMIT ISSUED------------------------------------- ----- DATE------ ---------------------------------------------------- Alterations and/or recommendations: -------j---------- ----- -------------------------•-------------------------------------------------------------------------------•--- _. - --------------------------------------•----------------------------------------------------------•-------------- --- ------------------------------------- --------------------------------------------- ------ - FINAL INSPECTION BY:. ---- -•---------- ---- Date- -�.S 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