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i 1} ' APPLICATION FOR SANITATION PERMIT Permit No. P: y (Complete in Duplicate) / — bate Issued Application is hereby made to the San Joaquin Loca4 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-_--------- -- --- .�� --- �--- -�� ------------------------------------------------ OvVner's Name------------------- _U �_.��_�C,._ -------- Phone__!_�c { , Address1 c Z7 - ------ ----------------------------------------------------------_.------------------------------------ Contractor's Name----------- ..'.'I-„�`"� Installation will serve: Residence ® rtment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _,_`Number of bedrooms___ Number of baths _ __. Lot size �r _u_r .----------------------------- ------- 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 �ew Construction: Yes ❑ No E!' 'Y ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cetspool permitted if public sewer is available within 200 feet.) � 4 Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material____________.___________._______________________- ❑ No. of compartments----- --------------------Size-----..-------------------------Liquid depth---------------. ----Capacity --------- Disposal Field: Distance from nearest wellJ"0........Distance from foundation__J_q-----------Distance to nearest lot line.NC........... Number of lines---------)------------------------Length of each line-----_3_'__�_ , Width of trench ---�_iC-.................... Type of filter material_,---------.Depth of filter material-- �.__- Total length_ a------------------------------ Seepage Pit: Distance to nearest well---------------------- 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-________________-______________ rn [] Size: Diameter-------- --------------------------Depth--------------------------- ------------Liquid Capacity----------------- --- -----gals. Privy: Distance from nearest well_____________________________________________Distance from nearest building--------------------------------------- ❑ Distance to-nearest lot line---------------,--,,-----�� --------"---------�----`----------------------•-••--- ----^--'--------•-------------------------------------------------- Remodeling and/or repairing (describe:__.____._.k—c """�'v� `�' t., --- ---------------------- ------••- --------------------- 1�-------------------------------------- •- rp. __________________ _______.._.____..__.____________.__________-_________________________.______________-__-_______________________._______.._._____-�..----------------------------------------------------------------------- ]ice __________________________---------------------------------------------------------------------------------.___....__.-------------------------------------------------------------------------------------------------------- r ---------------------------------------------------____--------------------------------_........____---------------------------------------------_-------------------------_-----------__------------------------------------- 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. t (Signed)--------- -�'r ----------------------------------------------- ----------.(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 APPLICATION ACCEPTED BY------- DATE----------------------------------------------------------- REVIEWEDBY-------------------------------- --- ---A_ ------------------------------------ DATE-- - __~ r- �^ BUILDING PERMIT ISSUED------------------- ----------------- DATE------- / --j " ------ . Alterations and/or recommendation s:_____ �'"_ _r �._____� _..---.----: - ----.--- �`Y�-�J------ 7.-.-- a --- ------------- ------- ---•-------------•-•-----------•------•-•--•----- - -------------------•------------------•--------------------------------------------------- ------------------------ --------•--------------------•----------------•--------------------------------- •----•--------------------------------•------•--------•-------•--------------------------------•-------------------- -------------------------•--------------------------------------------------------------------------- --------------------------------------------------------- --------------------•------------------------------------------------------------------- ------------------------•------------------------------------------------- FINAL INSPECTION BY:.---- - ------------------------------- Date_... . = -tl'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 ; Revised W-2140