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APPLICATION FOR SANITATION PERMIT Permit No. .................. r (Complete in Duplicate) Date Issued A-15-5— ,r �AA�plica+ion is hereby made to the San Joaquin Local Health District for a/permii.tfnstruct and install the work herein described. Ts application is made in compliance with County Ordinance�lo. 549.10 JOB ADDRESS AND LOC ON--- ... f ----- C ------------ -------- ------------ -----------,----- -Owner's Nam p -------------- -------- Phone- ,./ -- ,, 1&_ / Addres - -? ------ ------ ----------- ---------- -----------------------------------------------------------------------------------...........-•----------------------•---- -- Contractor's Name---------- ----- --�'.�.:�`- -1---- ----- =''------------------------------------------------------------------------------ Phone---. -- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units:/------- Number of bedrooms I"-__-_ Number of baths _-.- Lot sizes ll'si 67------------------------- Water Supply: Public system` Community system ❑ Private ❑ Depth to Water Table/ t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No E]TYPE OF INSTALLATION AND SPE CA IONS: ll (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well,—:;'."_._-Distance,f o oundat;on__-_-- -_ . -•------.M ter I:-j-- --•--•• ------- ----•--------• No. of compartments_�...............Size_,_< l�Liquid depth... ..__- --- --------Capacity..... Dispos I Field: Distance from neares well 22?'Distance from foundation..,-/.Q.........Distance to nearest lot I; e.._._. ...... ` Number of lines----.,----------------- ------Length of each line............_ c ...._._.._...Width of trench--.._�_-.--------...._._ /Z ,' Type of filter material, 'it�-----Depth of filter material....1 ---__---_.Total length---------- Seepage Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line----_.-.._._ ❑ Number of pits----------------------Lining material...--------------------Size: Diameter-----------------------Depth--------------------_..__.._.__._ Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material_.__-__..._.-_---------_-..._.._----.. ❑ Size: Diameter Depth _ Liquid Capcity.....................------gals. Privy: Distance from nearest well.................................................DistanXarear st building..._......._...__:______.__-_.....-..._._. W ❑ Distance to nearest lot line.------ --------------------- ---- - ..--------•--------------•--- ------------------------Remodeling and/or repairi (describe :_._-------------•----_.-----------•-----------•-------------- --------•--------•• -------------------=------------•--------••----------- -------------------------- ---- .--••- . ....---�-- •--------------- --•--- ------------------------- -- --------------------------------------------- - ---------------------------------------------------------------------•---------------------------------------------------U --------------------------- ereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I nd r a regul s of the San Joaquin Local Health District. (Signed) ' .' �- ---. Owner an ontractor By:---------------------------_------M--- ----- -- —--- ------------------------------(Title -- -- ==''� - 1 (Plot plan, showing size of to , location of system in relation to wells, buildings, etc., can be p d on reverse de). FOR DEPARTMENT USE ONLY APPLICATION'ACCEPTED BY---------------------------------------------------f/ '. ------_-------------------- DATE................. --- ------------- REVIEWED -- - REVIEWED BY-------------------------------------------------------------------------------- .......................................... Jt " •- ' ' ------------------------------------------ DATE------------------------------••------•---................ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------- ------ Alterations and/or recommendations---------------_--------- -------------------- ---------•----------------------------------------------------•--------------------...---------------------•-•- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---. ----------.---------------------------------------------------•------------ ............................................................................................................................................ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------•----------................. ------------------------------------------------------------------------------------------------------------•..----------------------------- 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 Revised W-2100