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r APPLICATION FOR SANITATION PERMIT Permit No. ..1.3_�..�'... (Complete in Duplicate) 7�7 .Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install ts�hglej� "'r This application is made in compliance with County Ordinance No. 549. JOB ADDRESSRALOCATION--�--__ _--,___- (JW4 G�y.. ,rr �"'►✓ '�Owner's Name- - -- -- ----1' -•-•.� - ----------,-------- ------------------------ ---------------------------- ---- Phone1.0-7.1.•--31--------- Address-----_----• --- ------- ---- Q Contractor's Name -- ''� !f�� ---------------------------------- -- .... Phond.. 'T Q a -•---- ---•------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motell ❑ Other ❑ Number of living units: _.`___ Number of bedrooms xr -_ Number of baths ---!-- Lot size .-_•-_.____-__---.__.-_ Water Supply: Public system ❑ Community system ❑ Private Depth to Wafer Table .4-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Lo ❑ Clay E] Adobe El Hardpan ❑ Previous Application Made: Yes ❑ Now Constru tion Y s No L t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is availa le within 200 feet.) SepticTank: Distance from nearest well_________________Distance from foundation------.-------------Material-_____-_-__________--__________--__--.-_---____-. ❑ No. of compartments-- -------------------�Size-_---_----------- --...Liquid dept----------------------- Capacity--_-------•--------r- Dispos field: Distance from nearest well-_-,��_ _-_Distance from foundatiq�yO -------Distance to nearest lot line----1*..... - Number or lines--------�_ _ Length of each line.______________ _-_-_.Width of trench__ T� ype or filter material ______ ____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 Capacity -- --------------gals. _. _ _- Privy: Distance from nearest well--------------------------------------------____Distance from nearest building------------------------------------------ 4e ❑ Distance to nearest lot line------------------- 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 ordinances, State la , d rules and regulations of the San Joaquin Local Health District. A (Signed) ------- ------ ------------------------------------------------------- -____.__ 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------------------------------------------------------ --i-y�---------------------------- DATE--------- -- REVIEWEDBY------------------------------------------------------------------------------------------------------------- ---------------- 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 10-52 Revised W-2100