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i1j y`� , gg `` APPLICATION FOR SANITATION PERMITPermit No. (Complete in Duplicate) 0� Q Date Issued ._--- Application is hereby made to the San Joaquin Local Health District for a pemit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. ' I_1 -------------------------------------------------------------------------------- JOB ADDRESS D.�OCA;f��1 � ��---------- Owner's Name - ---------------------------------------------- Phone-� � Address--------I_ZO 21/. �4 ------------------- --------------------------------------------------------------------------------------------------------- Contractor's Name---- ----- ------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence [v�/Apartment House ❑ Commercial ❑ Trail r Court ❑ M .'el ❑ Other ❑ Number of living units: Number of bedrooms -= Number baths _ Lot size __ _`_ _<�______________ Water Supply: Public system ❑ Community system -❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;'ONo Clay Loam E] Clay ❑ Adobe Zardpan E]Previous Application Made: Yes E] No M"' New Construction: Yes ❑ W TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public fewer is available within 200 feet.) Septic 'ank: Distance from nearest well----- =1/-_____Distance``��rom f unda ion__Jj0*_-_.Mat/-r-al- ------ --------------- -- ___----__--. S No. of compartments------------ ----f.__SizeL_!� _ -�x�Liquid//degth______��------_------Capacity..__ -_�:d-- Dispos I"Field: Distance from nearest well ---.- -----Distance from foundation---!_0._-/_._Distance to nearest-lot lin __rr_..__ _-- L Number of lines___________ _____ _____ __ __Len Length of each line__--_-_-.�_ Width of trench-------- - _- g - r� ---------------- Type of filter materi -!Depth of filter material-----1_$-- --.--Total length-----�--------____________________.- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-___--:-------_-. f ❑ Number of pits----------------------Lining material---------------------- Size: Diameter-----------------------Depth-------------------.-------- _-- -----------------Distance from foundation material----------------------------Cesspool: Distance from nearest well El Size:Size: Diameter ----------=------------------------Depth---.--------------------------------- --------------Liquid Capacity-------------------------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------.-----. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe) --------------------------------------------------------------------------------------------------•---.......--------------------•---=----------- --------------------------------•---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with-San Joaquin County (i ordinances, State laws, ap4 rules and regulations of +he San Joaquin Local Health District. 01!(Signed) __` . V -•--------------------------------------.-.----------------------------------------------------------------(Owner and/or Contractor) --- - - - -- -- ----- ----- ------- -- -- - -------------------- Title ---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, a+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY_ ---- - ----- ----------------------------------------------------------------------- DATE- ,.rte--,----- ------------------------------------------ I. REVIEWED BY------------------------------------- -----------`-------------------------------------------------- DATE C1 BUILDINGPERMIT ISSUED--------------------------------------- - ------------------------------------------------ DATE----------- ------------------------------------------ III Alterations and/or recommendations----------------------- ---------------------- ----------------------------------------------------------------------------------------------------------------- ' ----------I-------------&" ----------------------------- ------- - P t'-------------------•----A--------- --------- ---- , �c, ';1,.�----------------------------- Gc ` - - ; _ P ¢a1 • c .� ,' - '' °f------ • -------- = ''-------------- ------- --- r .� l 4 kl FINALINSPECTION BY-.,, - --- '� ---------------- Date------------------------------------------ ------------------------------ 3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 Wes+ Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Man+eca, California Tracy, California I ES-9-2M 8-51 Revised W-2100