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x a SEP-` �-. ca_C4 APPLICATION FOR SANITATION PERMIT Permit No. _.. .. (Complete in Duplicate) ,r Date Issu 1-Q- :�`.tl 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., JOB ADDRESS AND LOCATION..-.Q.1_..•.. 3 �r.!^! ( G Owner's Name.......11f,41-- ....... - - -- ........ ------------ - ---------------------- Phone-.X.------------------------------- Address �fJtC� ....- ------------------•. -------- Contractor's Name..---- -------------------------------------------------------------------------------------.................... Phone----------------------------------- Installation will serve: Residence Do Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..---- Number of bedrooms --3.. Number of baths ..1--- Lot size .7Y-x-.-- ..�d................... Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table _. . ft. Character of soil to a depth of 3 feet: Sand- Gravel ❑ Sandy Loam X Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No NJ New Construction: Yes V] 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 well---I-v`/rDistance f%-found _Material --- .Size. ._Li uid depth-.No. of compartments Capacity-- -_ �--- -- _--- Disposal Field; Distance from nears t well - er istance from foundation _�,� Distance to nearest lot li e C� Number of lines ... -----------------------Length of each Iine Gf�✓�� OVidth of trench - - -- ----.-. Type or' filter material. p .,�" yp .! 40 C/.�..Depth of filter materiaLJ�"... _..c._..:Total length..-.._ _.Q...�' ......... Seepage Pit: Distance to nearest;well----------------------Distance from foundation-----------------•.:Distance to nearest lot line_....-.-....._-� ❑ Number of pits- ---•--------------Lining material-----------------------Size: Diameter--------------.---------:Depth------------,------------------7- Cesspool: ------. -----.-_- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ material------------- - ---------- ------------- Depth---- ----••--•-------------------- --- -,..'Liquid Capaci gals.Diameter x Privy: P� ' Distance from nearest well-_:-_-------------------------------------------Distance from nearest building.----------- --------__ _--._.-. ❑ Distance to nearest lot line--------.------------- ----------- `--.. Remodeling and/or repairing describe):------------ - --- - ------•-------------------------------- -------- -------- ------- ------ -------------.------. --------------------•------------------------------•---------------_-------------------------------------------------------------------------------------•----------------------------------- ------------------------- -•--••-•------•.............................---------------------------------------------------------------------------•------------------------•---------------•------------------------••------€ -------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------------------------------------------------- I hereby certify thaf] have prepared this application and that the work will be done'in accordance with San Joaquin,County ordinances, Stateflews, and rules and regulations of the San Joaquin'Local Health District. (Signed)...................... 1 ---=----------------------(Owner an 'or Contractor) B • Tale --- --- ------ (Plot plan, showing size of lot, location of system in relation to wells,buildings, etc., can 6 placed-,on reverse side). FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ---- --------------------------------------------------------- DATE....... REVIEWEDBY-----------------------------------------------------_...--------------------------------------•---------------------------- DATE...................................------------ BUILDiNG PERMIT ISSUED.........................................................-------------------------------------------- DATE.................................... Alterations and/or recommendations ------------------- ------------------------ •------... - 4 --------------------------------_........---------------------------------------------------------------------------..................................................#........................ -------------------------------------------------------------------------------------- --------------•-----_--------------------------- FINAL INSPECTION BY:. ------- -- = ---------- Date--=---_--------------_- ...... - 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