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1 APPLICATION FOR SANITATION PERMIT Permit , t1 (Complete in Duplicate) r% Date Issuedk____'_- -_-'_ 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 with County Ordinance No 549. / JOB ADDRESS AND LOCATION______ _____ -/ - : - /11 --- ---- Owner's Name-.---------------- s - ------------ -- -- -- Phone --- ------ ---- ------ /J •� � • -'- ------------ Address � " - Contractor's Name-------------- ame---- L,1-- .x -f------- U -- ---•--- t-- ----- L �YFPolie__. - ---- ------ s._r ,� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms J___ Number of baths -----J Lot size __!-_ _ ____ _l.___ ------------ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table�,'!_ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Lo��No Clay Loam E] Clay ❑ Adobe 'I—Hardpan E]Previous Application Made: Yes ❑ No New Construction: Yes ❑ 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 foundation--------------------Distance to nearest lot line____-_---___.__. ❑ Number of lines-----------------------------------Length of each Time---------------_--------------Width of trench______________________________ Type of filter material ______________----__,_eDepth of filter material----------- ------------Total length----------------------.__.________.___._ Seepage Pit: Distance to nearest well_- __.Distance f orr} foundation - _v___ ___ _Distance,to nearest lot�line� f----------- Number ___ Number of pits___ "- Lining material_ { - :-r?.___ Size. Diameter -.�` Depth _____.i_ Cesspool: Distance from nearest well-----------------Distance from foundation_ _ __---------.---.Lining material-----------------------.-------- ---- Size: Diameter-------------------- -- ❑ - - Depth--- ------ - ------ - - - _ - -___Liquid Capacity -- ---- --- ---------gals. Privy: Distance from nearest well---_--- -_--- --- --------------- from nearest building------------------------------------------ Fl ___._-____.____ ------------- -- ❑ Distance to nearest lot line------ - - ---- --------'--- - ------------ ----------------------------------------- --------------------- Remodeling and/or repairing (describe): ' t ------------- ----------- -t-------- ----- ----- < -"-- -- --- - -- -------- -- ----- ---- --- _- - -------------------------------- ---- ---- --- -- - - - f ------------------------ - Y' — (. ---------------------------------- ----- -------- ----- - - ---- ----------------------------------------- ---------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. i 1 (Signed) r a' -- -g ----• '- - ;( `� -(O =and/or C tractor' u¢ 4 i cs�= By:--------- --------------- - ---- ----- �.------------------------------------------ -------------------------- (Title)---- _-r- -- - ---- �-----=/ -';--- ------ (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 - / g-----15-6/--------------- REVIEWEDBY---- ------------------- --- - ------------- -- -------------- ----------------------------------- ---------------- DATE------ PERMITISSUED------------------------------------------------------ - ------------------------------------------ DATE------ ------------------------------------------------------ Alterations and/or recommendations:-------- ----- ------ ------------------- ------------------------------------------ ------------------------------------- -------- - ---------------- ----- ------------------------------------------ ---------------------- ------------------------- --------------------------------------_ _------------------------------------------------------------------------- --------------------------------- ------ -------------------------------- - --------------------------------•------ ------------------------------------•- - ------------------------------- FINAL INSPECTION BY:._ Date.... ._�-----J------�--"-------- ---,-- --C--- ---------------------------- -------- ------ -- ___-____ 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