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bl _ APPLICATION FOR SANITATION PERMIT Permit No. ...1a....3....30.............. \� 2- I () (Complete in Duplicate) 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 .sS--------------�_At. = Owner's Name-------------------•---•--•----•---------4FLk .....----t.1,9&J.W- ------ ------------------------------------------------------ Phone------------------------------------ Address.................................... Contractor's -----------•----------•---•-------- Address--•----•-----------•-•------•------ Contractor's Name--------------------...................... ----------•----- ---------•---------- --•--------•-------- -•-•-- Phone............---------------------- Installation will serve: Residence'T Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms --2--- Number of baths ----!-- Lot size _..__.../ `�_ ---- -----2_4.Q__�________________ Water Supply: Public system ❑ Community system ❑ Private f Depth.to Water Table ft. 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 ❑ 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______.---._Distance from foundation-----/0._---------Material--___-"- Ftj' �__-_------- No. of compartments.__...... .........:.Size___.SX_ _.X -_,__.Liquid depth � . ----------- --_-_---_ Y _ SA i � Disposal Field: Distance from nearest well-_ -.��--_....Distance from foundation------?.f?------_.Distance to nearest lot line_____...... Number of lines----------------3--------------Length of eA-6'►li ----uo--!oo-t -Vr Width of trench-------_-�,f�r--------------- Type of filter material-------- Depth of filter m erial------/.f�, Total length----------- �A � '.---_____--. Seepage Pit: Distance to nearest well _-. -_ _Distance from foundation ,Die to nearest lot line----------------- Number .......... ...Number of pits----------------------Lining material-----------------------Size: Diamet ----: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 ❑ Distance to nearest lot Fine------------- Remodeling - -- --Remodeling and/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 ordinanves, State laws, and,,rules and regulations of the San Joaquin Local Health District. (Signed)-wrowing ..---------------------------- --------------------------------------------------------------------------------------------------.(Owner and/or Contractor) By ---------•-------••---•-• - ----------------------------------- --------------(Title)--------------------------•------------------------------------ (Plot plan lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..--- -•------ ---- v-S DATE --F. _ ��- y . REVIEWED BY.J.-----•----•-----•-•• ( ------------ DATE------ -------------------------- - -------------- ----------- BUILDING PERMIT ISSUED -------•------------------------------------------------ ------ DATE---------------------------- Alterations and/or recommendations:---------'- ------------------------ -------------- ------------------------------- ----------------------------------------•----------------------------------------•-------------•--•--••-•----•--- ---------------------------•------------------------------------------------------------------.------------------..---------------.---------------------------•--------•----------------------------------------------- ir ----- /� s FINAL INSPECTION BY:... - -- ------------ -- Date 1 _. 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 0-52 Revised W-2100