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` APPLICATION FOR SANITATION PERMIT Permit No. d...... (Complete in Duplicate) Date Issued � G Applica+ion 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 LOCA ON---- ---••- -• -aer�-._-'" '� -•L ..- `. ,) l I� Owner's Name ----- --` -------------------------------------------- Phone......... -------+�" '--------•--- __. _. -- -� 3------ Address------------ - ��----------- -- ---- - - --- ------•-----•--------------------------------_..--- Contractor's Name _4 Phone �- �tt_O-f Installation will serve: Residence [�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ / Number of living units: __/`__ Number of bedrooms .3--- Number of baths __L Lot size - o��____ _.� _�_�_________________ Water Supply: Public system UKCommunity system E] Private [-] Depth to Water Table �ft. Character of soil to a depth of 3 feet: Sand ❑ ,Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ Adobe[B/Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes P-No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T�n'k: Distance from nearest well_f4_oKG__Distance from foundation---L_-2----------Material__________________ ________ ___ No. of compartments-----I-------------------Size.�`_'_+�._A3-•(�.`'__:---Liquid depth__.�6`_'._________Capacity...9om Q _________ Disposal ield: Distance from nearest well_l� ......DistaPcd3from"ounation.....d_n�-----Distance to nearest lot line_.__--'___. [ �E Number of lines____ ____________ ___ _______Length of each line_____--7__,S!'_____..______.Width of trench._Z.-V—__'_______-__-________ Type of filter material___ ��-___________Depth of filter material------/��___._-Total length-------J'"�--_--------•---__-_- Seepage Distance to nearest well-W670--.0____Distan,c`e om foundation-----.�..2_------Distance to nearest lot line____.)_`___ uk Number of pits----l---------------Lining materiaK±�-------Size: Diameter_._Z ... p Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_____________________________________. ❑ Size: Diameter--------------------------------------Depth------- --------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 171 Distance to nearest lot line----------------- --------------------------- --_------------------------------------------------------------------•-----•---------------- Remooddelm and/or r prnn �esc rbe):-------- -------------•---•-- ------•-•-•---------------------------------------•----•----•--•-----------------------•--------•-------------------- ------------•-----•-------- •-----•-•---•--••-----•--•--•--------------------------------•------------------------------------------------------------------------------------------------------------------------------ I hereby c rti that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a ws, anZulesnd regulations of the San Joaquin Local Health District. s (Signed) -- ---•-------------------------------------------------------------------- - ----------------------------------- - Contractor By:--------------------------------------------------------------------------------------------- - (Title)- -- --------- ------------- -------- (Plot plan, showing size of lot, location of system in relation to Is, buildings, tc., can be pl cad on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BYS ZJ'--------------------------------------------------------------•----------•----------- DATE-'C� .....-..............................------------ REVIEWEDBY_------------------ -- -------------------------------------------------------------------------- ------•--•- DATE-- �-S .................. •------------------------- BUILDING PERMIT ISSUED............................---------•----•-----•------•--------- •----- DATE_•----------------- ----- ------------------------ Alterations and/or recommendations:...........................................................................................................................•--------•-----------...----------- ------------------------------------- ----------------------------------------------------------------------------------------------------•--------•-----•---••----••---•------••---•--------•------------•--•-•-•---•••--- ------------------------------------------->-••---------------------------------------- --------------------------------------------------------_------------------------........................................... ---------------------•-------------------------------------------------------------------•----------------------------------------------------------•------------------------------------------------------------------•----- ----------------------------------- --------------------------------------- -----------------------------------------------------------------------------------------------'_._.._...__..---•-------------•--••-•-----•-- i FINAL INSPECTION BY: - Date f_.-/ 7 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