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_iv � M APPLICATION FOR SANITATION PERMIT Permit No. ... (Complete in Duplicate) � ''�� Date Issued ... Applical-ion 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 LO ATION--- F ------ ' ---------------------------------------------------------------------------------- Owner's Name--- --- 1.--- ---------------------------------- ---------- ------------------------ Phone------------------------------------ ~ 111 Address----- y ' �.l _ ------ /�r� Contractor's Name_____ __________ _____________ Phoned_f�_�= __�r.�__�.0_°__. - ------------- ---------- Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 'Other ❑ Number of bedrooms _-02. Number of baths .L____ Lot size ------X--110-0_______________________ Number of living units: __1____ Water Supply: Public system A--inmmunity system ❑ Private ❑ Dept h'to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobet�Hardpan ❑ Previous Application Made: Yes ❑ No I New Construction: Yes ❑ 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 we4ej4�__.Distance from foundation----140� --------Material_ _________________________1_____111 -� No. of compartments______.--------.. Size__ "+ _11�_ i __.___Liquid depth___ _ _____________--Capacity___s�J Disposal Field: Distance from nearest well-----------------Distance from foundation__________ ________Distance to nearest lot line----------------- _�7% Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material_-__- _____________Depth of filter material------------------ -----Total length-------------------------.---------------- Seepage Pit: Distance to nearest.well_011*1i-A____'_Distance from foundation____.2_A_f _ Distance to nearest lot line--_X ........ 66, Number of pits______ _____________Lining material... -Size: Diameter_. _!_4_ ___De th_ . r } r ► Cesspool: Distance from nearest weil...................Distance from foundation-------------------lining material_____.______________._______.___-___-- ❑ Size: Diameter--------------------------------------De th------------------}l----------- -----1111-. ----Liquid Capacity --------------1111------- gals. Privy: Distance from nearest well.-_.______.__,-}_______________________________Distance from nearest building------------------------------------------ � ❑ _ Distance to nearest:lot'iine-"- ----- .� . _ ._. ------------------- ----------•--- --- ----------------------------------------- Remodeling and/or repairing (describe :_`--------------------- -.-------. -- 1 ----------•-••-----•-•----------------------------------- �....----. ----------- -------•------------------- ----------------------------------------------------------------1111-11111.11--1111-- ------------1111.- e - -------------------------------•-------------------------------------4------•---------------------------•-•--------.......-----1111-•1111.111--------------------------------------------------------------------------------- ----------r------------------------- ---- ----•-----------------------------------------------------------•-------•-•-------------•--------------------------------•-------------••------•-----------------------------1111-- I hereby certify that I have prepared this-application and-fhaf the work will,be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of fheSan Joaquin Local Health District. i 5 a cy r (Signed)----- 49weer�and�w Contractor) • - '' "' ""c=-------------------- sY= w ----•--------- -----(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----- -------------------- DATE -------------- REVIEW-ED`BY------------------------- --------------------------------------------------------------------------------------------------. DATE-------------------------------._------------------------- BUILDINGPERMIT ISSUED------------------ ------------------------------ ---------------------------------------------------- DATE----------------------------------------------------- ---- , Alterations and/or recommendations--- -=--------------------- -------------------------._.:.. ---------------•--------------------•-----------------------------11 i =--- .. --------------------- -----------------------------_-------------- •------------------ •----11-11-------•---------- -------------------------------------------------------------------------------------------------------11- 1.1-------- ------------------------------------------------------ _".____________-__.____._.___--_...___.._-_-._---.-_-_11___11___________._______.__________._.._____.___ _________________ _ ______.__.____.______.______-_._.-_. f FINAL INSPECTION BY:_...:- =1_- ------ L5 5� -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Woof 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M - Revised W-2100