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-12 APPLICATION FOR SANITATION PERMIT Permit No. ...s ...fl)..S_ /�' (Complete in Duplicate) i/ �"�I `� Date Issued ------7Appl.i<ca4ion`is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. pplication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_____________�__ �_-1--4_ .A1_,—___.-_..___._--________---_-_---------------------------------- Owner's Name �-- ..� . .. . ' __ Phone.................................... ,` , Address Q- ✓° =C�l-? ----------------• Contractor's Name. -41L IWO-''5-------------------T------••--------------•-------•--------•--. Phone. .L...�._.ItU Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ y Number of living units: __/_____ Number of bedrooms Number of baths _:: ... Lot size .__ _ _..__..11. L�........................ Water Supply: Public system ❑ Community system ❑ Private �& 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 Ta IJ � is ante from nearest well_________________Distance from foundation....................Material-------------------------------------------- N of compartments--------------------------Size---------- --------- --_._._Liquid depth--------------------------Capacity........................ Disposal Field: Oistance from nearest well-_______________Distance from foundation--------------------Distance to nearest lot line................. ❑ r of lines----------------------------------Length of each line------........................Width of trench------.-------------- ------------- Ty " of filter material--_._ _-___.___-___:Depth of filter material---_-___ _____.•___--.Total length__________________________________________ geepage Pit: Distance to nearest wpll------9L?_---------Distance from fo nHati n....../_ _....Distan 13 to nearest lot line__1.4.`__.._ Number of pits__..._____'__________Lining matenaL_�.-�_-!�:_4-�i�'.�3iameter___�_�f-_____Depth---- :' ____............. Cesspool: Distance from nearest well-----------------Distance from foundation ______,_____.Lining material-------------------------------------- 171 _. __-___ --_ ._______--__-___.❑ Size: 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, Sta"ws, and rules and regulations of the San Joaquin Local Health District. (Signed) C - -'- .....ti_.'—L ( -----�vr and/or Contractor) ----- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPART+ENT USE ONLY APPLICATION ACCEPTED BY--- --------------- ------ ---------------_---- ...--------------------- DATE-- ---- ------------------------------------- REVIEWEDBY--------------------------------------------------- --- -------------------------------------------------------------- DATE----------- N -------------- BUILDING PERMIT ISSUED------------------------------- ------ ---------------------------------•---- DATE --- ... Alterations and/or recommendations:--_----------- --- - ----'tel --------------•---•-------••--•-•---•----------- ...---•- ....... � - ---------------- -- - ------ - ------------------ ----•----------•----- --- f -- -- --.... -------------------------------------------- -------•------------------••------•-------.....-•-----•---•-------•-••..........-•--•----------------•-•---------......_....-•--••-•---------•---•--•----•---•---•---•--••-••••-• FINAL INSPECTION BY:---------- S-----_-------------_------ Date-----1k- .....1-+ 10•^-- 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