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l' APPLICATION FOR SANITATION PERMIT Permit No. .__ 0 �..__ (Complete in Duplicate) 3 / Date Issued 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 Gwith /County Ordinance No. 49. JOB ADDRESS AND LOCATION-__-�4-ff-LF - Owner's Name- ,dj r,z_'�.,J. �---..C.. --$ --------- -------------------------------------------- Phone.................................. Address <'• -- - ---- --. . . -------/--------------------••------/- •- c Contractor's Name----- -- --------------- Phone�6 ._►J'-_= G.f !'- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unit s Number of bedrooms •__Number of baths J--- Lot size .....!_4S______ <.___hnQ.................... Water Supply: Public system °ommunity system ❑ Private ❑ Depth to Water Table .ff..�t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 6—New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well_________________Distance from foundation-----h d--------Mate{ial.... ____ ------------- No. of compartments--.--.-3- ---------Size__J--fi A---0----Liquid depth__._- _`._........Capacity__ �-------•--- Disposal Field: Distance from nearest well-----------------Distance from foundation... ,.5__�..__.Distance to nearest lot line--- [ - Number of lines-_-._______/- -ill-j_ __Length of each line___-_,e'ZS=_-`_-____-.---.Width of trench-----,�.5�:.___`________________ Type of filter material-__- __�,__.__1. . __Depth of filter material___-_ ...'---.!otal length-------�------------------------- r Seepage Pit: Distance to nearest well----------------------Distance fLom fou dation__=-zd..__.Distance to nearest lot line-.-/— Number of pits--------/__.-------Lining material...B _'tom/_ ._ _-Size: Diameter__--3.3.. .........Depth----- Q.(---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ElSize: 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 I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law;, and ru s and regulations of the San Joaquin Local Health District. t E- i� (Signed).... _.. __ l°« Contractor] --- - -------- ------- ---------- ------ --------------------- ---- By:----• -- -------------------------------------(Title) ^' (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 n DATE-------_---- - "'' '-------------- REVIEWEDBY...........•-------------------- ---------------------- DATE----------- ---------I............................... BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendationsi-•------------------------------------------- -------------------------•---------•---------•--------....------------------------------•----------------------- -•----------•------•----------------- ---------------------------------------------------------------------------------------•-------------•---•-•-----------••---•--•--------....................................... ---•--•---•-----------•--------•-----•-----------•-----•••---...----•---------- -----------------•--•-----•-•---------•-•-------•-•-•----•--....--•-•-------•----•------------•---•----------•------•----------••----------- --------------------------------------------------------------------------•---------•---------------------------------------------------------------------------•------------------------------------------------------------ -------------------------------- ---- ----------- ---------- ------------------------------------------------------------------------.---- .................... If I-r FINALINSPECTION 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