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+ APPLICATION FOR SANITATION PERMIT Permit No. _.I- --��-- (Complete in Duplicate) Date Issued .__-- -?-��--s_� Cb5—r3o 3,� Application is hereby made to the San Joaquin Local Health District for a permit to constr� nd6nstall the work herein described. Th is,application is made in compliance with County Ordinance No. 549. �� JOB ADDRESS AND LOCATION__ '--�-- ----�--<-==1- 's Name---- ------ - - ------------------------------------------ Owner Phone----------------------------------- Address / ------------------------------------------------------------------------------------------ ------ v �''r Contractor's Name--- '�' - Phone___________________-___.-________ - ---------------------------------------- Installation will serve: Residence F-1ApartmentHouse E] Commercial ❑ Trailer Motel ❑ Other ❑ I Number of living units: -1------ Number of bedrooms P--__ Number of baths Lot size ------- -------------------------------- Water Supply: Public system ❑ Community system ❑ Private k Depth to Water Table .-eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [X Clay ❑ Adobe'❑ Hardpan ❑ Previous Application Made: Yes ❑ No 54 New Construction: Yes De No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - (No" septic tank or`cesspool permitted if public sewer is available within 200 feet.) n (" Septic Tank: Distance from nearest well__S.q_______Distan a from foundation__]U-________.Materia_________________________________________________ �A --------Size-- -- ---------Liquid depth------q-----------------Capacity-�-�---------- w No, of compartments-___i�-'____ __ +��`�--- � -Disposal Field: Distance from nearest well Distance from found �ion_t?__-.____-__.Distance to nearest lot line____ ___________N aNumber of lines__ __ _ _____ `` '____--�� Length of each line__- '___ -------Width of trench___�'�`4t -__�"? ------- Type of filter material,,�_•�-_AW-- -Depth of filter material-Jor.-'_____-____Total length=_______S?_E1____-______ Seepage Pit: Distance to nearest well--- -------------------Distance from foundation------------------..Distance to nearest lot line______________-_ ❑ Number of p:ts----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-________- ._Distance from foundation------------------- Lining material------------------------------------- 1 ❑ . . _ Size: Diameter------ -------------=----------F Dep+h -----------------------.-------Liquid Capacity-- ------------------------gals. i Privy: Distance from nearest well---------------- --------------------------------Distance from nearest building-------------------------------------- _ ❑ Distance to nearest lot line------ ----------- --- -•------- -------------- __._.-_--_-`------------------------------------------ - Remodeling and/or repairing (describe):------------------------- ----------'-------------------------------------------------------- ----------------------------------------------------------------------------------------- --------------------------------------------------------------- --------- -------------------------------------------------•------------------------------------------•------ ------------------------ •------------------------------------------------- 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. ------------- ------------------------------ (O and/or or Contractor) (Signed) + J ----- ---- ------- ------------------------------- --- - we ----------- (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__l -- i-'•�" --------------------------- REVIEWEDBY------------------------ --- ------ DATE------------------------------------------------------------,' BUILDING PERMIT ISSUED----------------------------------------------------------------------------------- --- DATE--------------------------------------------------------- Alterat' ns � r rec en tions:-------- - ----------- dct ------------- --------- --- ---------- r ''`-Q ia�" --� C--- - ----- _ ----------- --------------------- --- -- �-`-� - p .. -------- ------ ----- i-- ------ ------------- - .� ------------------- FINAL INSPECTION BY:._ _ -��--�--�---------------------- Date !" 7 '` 9 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 1.57 F.P.Co-