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APPLICATION FOR SANITATION PERMIT Permit No. 6..4�-. �11�� (Complete in Duplicate) ld 5'",3 V\ 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. JOB ADDRESS AND LOCATION ----------- - --------- ------. --='--- ('�,� Owner's Name �--- . -- -•------------------- - ----- ------------------------ Phone... ' `� l Address ..---•••.--•- --..__... - ------ Contractor's Name............... - ---- ------ �W ._..i[ Phone............................. Installation will serve: Resid ce Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms -__-__ umber of baths ________ Lot size �_ Water Supply: Public system ❑ Community system Private ❑ Depth t Water Table Character of soil to a depth of 3 feet: Sand ❑ , Gravel ❑ Sandy Loam Clay L .am ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ 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 well"•-4-0-l7s�ance from foundati6F� .Materi I ----- No. of compartments._--_ ize___________________ ___________Liquid de th__ Capac�ty.. Disposal F' d: Distance from nearest well--2-6-0-_Distance from foundatio Distance to nearest lot lin t Number of lines_______ _______ _ _ ______ ___Length of each line.._____' _Width of trench.__ g Type of filter material._-�� l��yL- - __ _Depth of filter material___�_�_._____.__Total length------- �__.;� .............. Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- F1 Number of pits--------------- ------Lining material-----------------------Size: Diameter-----------------------Depth------ ------------------------- 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------------------------------------------ El _ _❑ Distance to nearest lot line----------------- - ---- ------ --------------------• ------- ----•-- Remodeling and/or repairing (describe): ---!/-- %-- t -------------------------••--------------� + - � ..._ •---•- .............................................---------------------------------------------------------.......................--------------------------------------- ------------•------------------------------------------------------------•-----•--------.............................................................-------------------------- ----------------------------------- --------------•......•------•-•• -••--••-•---_------•----••••--•------•-••---•-••----•----------•-------------•--•--••-------------•--•--•_---•- I hereby.•certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance, State laws, and rules and regul4tions of the San Joaquin Local Health District. (Signed) ------•----•------------------•----- ---------------------------------------------(Owner and/or Contractor) f. By:-------------- - -•-----------------------------•---------------------------------------------------------------------------------(Title) i (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 APPLICATION ACCEPTED BY - ---- DATE ------------ ---- ---- 9EVIEWED 8 -------------------------------------------------------------- ------------------- DATE..................... BUILDING PERMIT ISSUED--- -------- -------- -------- ------ DATE Alterations and/or recommendations:-__ _-_____________________________ t --- -- --- •--•-----•--. -- _----� ; •_ T'- •_- f -d--J---------------j---- ------------------ ------ ---- Ij 3 .. __ _ .. uuu¢ srw.. •-- ----- FINAL INSPECTION BY----------------------------------- e ----1, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 14 North "C" Street Stockton, California Lodi, California Manteca California Tracy, California ES-9-2M 10-52 Revised W-2100