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42,10 APPLICATION FOR SANITATION PERMIT Permit No. -------------------- ---- l� (Complete in Duplicate) Date Issued __7/r�- 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. JOBADDRESS AND L C TION----... -- - ----------------------------------------------------------------------- ....... ��jj Owner's Name Wil__ = -- ------- ----------- -- ------------ ------------------------------------------- Phone---t7` Address----•--------------------%3 ------... = Q.a ------•p•- --------•---•-. Contractor's Name. f -------- ------------------------------------------- Phone.. f- -Z7�'.__0_Z... -- ------------ Installation will serve: Residence a-'.'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _______ umber of bedrooms _ 0 � ,�. Number.of baths .__l_. Lot size ._.__�Q___�._� Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table _-yy'd ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Lo m ❑ Clay ❑ Adobe M--`Hardpan 0 Previous Application Made: Yes E] 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--------------------Material_-__-__--__.---.--..__.---_._-------._____-_..__. ❑ No. of compartments-------------------------Size--------------------------------Liquid depth----- --------------------Capacity---------------------� Disposal Field: Distance from nearest well .�' —Distance from foundationQ_ ..._...Distance to nearest lot line-_-_�--. [� __ 41 Number of lines________________ ________ __ _ Length of each line--------______..__________ Idth of trench......t_�!y_ Type of filter material...//*J..� ._Depth of filter material--_.-_-7��l g .t � otal lenth________ --------------------- 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 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�aws, and rules and regulations of the San Joaquin Local Health District. (Signed)---------------- -f1I -- ------ - --------- --------- ----------------------------------------------------- mower and/or 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-- - --------------------------------------------- ------------------------------------------- DATE_." ------------------------------------------------------ REVIEWEDBY------_--------------------- ---- ----- -------=-------------------------------------------------------------------------- DATE------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- ---------- DATE.......... ------------------------------------------------- Alterations and/or recommendations---------------------------------------- ---------------------------------------------------------------------------------------- ---------------_----------- --------------------------------------------------------- -------------------------------------------------------------------- --------------- ----------------------------- ---------------------------------------------------•------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- --�-----------------_--------------------........... FINAL INSPECTION BY---------------Av - -------------------- ------------- Date------------ Z ---� 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 10-52 Revised W-2100