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1� 1 I � \� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ----71, Applica+ion is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described. This application is mad11 e in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION / l� .,_.... ----- ---- ..-.. Owner's Name------ -------------?It,-l- $y Z--------------•---=--------•------------------=--------------•----------------- Phone.---------------------------------- Address -------------------------..---- Address-----------'� -- ------------------------------------•------------ Contractor's Name-------- Ct "�"' "------- -----••---------------------------------•-••--------- ••--•----------••-------- Phone-----_-------------------------- Installation will serve: Residence` Apartment House ❑ Commercial ❑ Trailer. Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms , •_. Number'of,baths ---I_.- Lot size _. _X____10---_-------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to'Water Table"_:-.--_ ft. 1 Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E] AdobeHardpan E] Previous Application Made: Yes E] No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank`or-cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest we1l-1/$/1t__Distance from foundation__ l� Material -Ct 4' No. of 'compartments----- - -------------Size_--� 5__?4__ __------Li uid depth ---------- ---Ca Capacity g_0__d_----- � �--- - -- - � q � -- P Y...-- Disposal Field: . Distance from nearest well_VPA—f—Distance from foundation____--0_.______-.Distance to nearest lot line______ -.__. N .,Number of lines___.__ Length of each line_ __________________Width of trench.cXx_.�R-_�--____________ rl Type of filter material-:5-4_ J_ ackiinth of filter material_-_ __;__Total length-------0 ___________________-____ f Seepage Pit: Disfan"ce to'nearest'well-______________-------Distance from foundation___..---------------Distance to nearest lot line_---_____________ S ❑ Number of pits----------------------Lining material---------------------- Size: Diameter----•------------------Depth---------------------------------- Cesspool: Distance from nearest well___._________Distance from foundation---------____________Lining material___.------- --------------- ----------- ❑ Size: Diameter-------------------------'----------- Depth----------------------- ------Liquid Capacity----------------------------gals. a Privy: Distance from nearest well---.-k.__----------------------------------------Distance from nearest building------------------------------------------ ❑ Disfance�to-nearest lot line__..__-" '------------------------------ "' ------- ' Remodelingand/or repairing (describe):--- -------------- ---------------------------' r----•-•• ------------------ •------------------- -------•------•---------------••---------------•-------- a -----------------------------------;---------•-------------------------...------------------------------------•---------------------------------------- I hereby certify that-1 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. Si ned Owner and/or Contractor) { w 9 } By:--------- -----------= -------------------------------------------------------------------------•-------------------------------(Tifle)----------------------•----------------------------------------- (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-----------�..---------------------------------------- REVIEWEDBY----------------------------------------=------------- -----.-------------- ---------------•-•-------------------- DATE-------�----�-f----------------------------------- BUILDING PERMIT ISSUED---------------------- �— ---------------------------------- DATE -- -- --------------------------- � -- -Alterations and/or recommendations:----------------- ------ - -- `-------------- -----------......-------------------- :::_.. ---• ----- J ------------------- ------------- ._ , ` � -- - ------------------------------------ -4. ff4:0%�-- --• Date_=:__ -----------------------FINAL INSPECTION BY:.___.- 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-2100 1