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V APPLICATION FOR SANITATION _PERMIT Permit No. _ __.- -- (Complete in Duplicate) /p rj 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. O _ JOB ADDRESS AND LOCATI z 2U4 Owner's -------- -------------- e-�. �-y ti, -------- Owners Name 15 a �L � ld._._.J`_ ------ Phone a Address v2 5 -- --- '� '� Contractor's Name----------------------------- Q�L1� - -----•- - --- Phone 4 E� ��--- p Installation will serve: Residence P5, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __../__ Number of bedrooms __v Number of baths __.,{___ Lot size -----IS-7 .-'-. --._ _Q__Q'____.__.__.___ 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 JZ Hardpan ❑ Previous Application Made: Yes ❑ No;9., 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 well3_tQ-,-_Distance-from foundation--- No. --- ---------.Material__ ...-- ---- ------------- of compartments__-_- . `r -------------- Size_.l` - -hyp ---Liquid depth `� ----------Capacity------._._ 4' t Distance to nearest lot line____./__ _ Disposal Field: Distance from nearest well-.t ._.____Distance rom oundation__ _.. .._. . Number of lines----------A----- _______________ Length of each line___cr_,_O_'---------.Width of trench._ `+�'_'--------------- 11 . Type of filter material--- _,....Depth of filter material ______./_9 .....Total length__A_Q_'__________________________ Seepage Pit: Distance to nearest welf--- _r_Distance from foundation__*._�_ _. _. .Distance to nearest lot line______,(_V..._� Number of pits.__.__._________-__Lining material�D>ar -------Size: Diameter___ _ _"..____Dept h_... Q!............ ____ Cesspool: Distance from nearest well _____-----------Distance from foundation------------_-------Lining material-_________-________._._______.______ Size: Diameter------------------------------------ --------- - ---- --------Liquid Capacity-------------- -------- ----gals. ❑ Depth----•---------------------- Privy: Distance from nearest well---____---------__---------- --------------------._Distance from' nearest building----------------------------------_-----. • ❑ Distance to nearest lot line------------------------------------------------- -------•------------------------------------------------------!------------- Remoda ---- -- ' . ----------------- elin ,/or rep ring (desc bel:___ - ---------------- - ---------- 1 ~ --------------------------------•-•--------------------•---•----------•------------------•---------------------------------------------------------------- --------- ----------------------------------------------------------------------•-----------------•-•-----------------------------------------------------•-------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I and rules and regulations of fk6'S`aji Joaquin Local Health District. ---- ----------- ---------- -------- ---------------------------- (Signed) Contractor) By:-----------------------------------•-•------•------------- - --------------- {Title} .�rszs (Plot plan, showing size of lot, location of sys in relation to wells, ildings, etc., can be plat ed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------------- DATE------ - - - �------- REVIEWEDBY--------------------------------- ---------.----------------------------------------------- --------------------------------- DATE-----------------------------------..__.----...- BUILDINGPERMIT ISSUED--------------------------------------------------------------•---------------------- ------ DATE---------------------------------------------------: ._ Alterationsand/or recommendations:----------------------------------------- ----- ---------•--------------------------------------------•----------•---------•--•-----------•------•------------- -------------------•--------------------------------------------------------------------------------- ----------------------.. -----•-------------------------------------------------------------------------------------------------------------- ----------------------------------------------- ---------------------- ---------------------------------- k ------- ------------ 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 10-52 Revised W-2100