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. t APPLICATION FOR SANITATION PERMIT Permit No. 42J . (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 AN,D/f/LOCATION U_0 v e �--- ---------,�-------------------------------- Owner's Name------ j �� ` U ------------------------------- -------------------------------------- Phone%'/�G�--AI-11 Address----------------------------- Contractor's Name----- - ---- -------S------le--a---/- --------- -- ---•------------------------------------------------------------------------------------------ Phone Installation will serve: Residence Ap ment House ❑ Commercial ❑ Trailer Court E] Motel F] OtherOther Number of living units: -- - Number of bedrooms _..�. Number of baths .-1_.__ Lot size -----------f--- Water Supply: Public system ❑ Community system ❑ Private WDepth 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.) h Septic T k: Distance from nearest well _ _____Distance from fo d tion--------------------- _-_-_/ -__-Materi L_ ED/ ---------Size---- '�.."s�N Liquid depth---------- p y- No. of compartments---.__ __-_ fe _ __--_Ca Capacity—j/4-0 Dispos ielcl: Distance from nearest well.__`-�----Distance from foundation-_--/V__F-__._.Distance to nearest lot line---_-___-.___. Number of lines-------------/_--_..._ .--_Length of each line____--__-ZV- -_._-Width of trench-------------2-'` -`� -------- Type of filter materials 4 ____---Depth of filter material-------I _-________Total length__-_-_-.----._--.fid__.._-_-__-_- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------- to nearest lot line_-__----__.----_ ❑ Number of pits---------------------Lining material---------------------Size: Diameter--------------- -------Depth------------------------------_-- Cesspool: Distance from nearest well-__-------------Distance from foundation------------------- 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):------------------------------------------------------------------------------------------------ ------------------------------------------------------- a ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ------------------------------------- ----------------------------------------------------------------------------------•----------------------------------------------------- ---------- ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that 1 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. (Signed)_ '� (Owner 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 REVIEWED BY----------------------------------- ------------------ ---- ----------------------------------------------------------- DATE -------------- -P J �- BUILDING PERMIT ISSUED--------------------------------- --------------------------------------- ------ DATE----------- ------------------ ------------------------ A aerations and/or recommendations:-- ------------ ----------- -------------- --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- --------------------------------- --------------------------------------------------- ----------- ---------------------------------- -------------------------- -- ------------- - ------------------------- ------------------ ----------------------------- ------------------------------------------------------- ------- /1 f FINAL INSPECTION BY:--------` '� :p ' ----------------------------- Date-.---�--" i 7-` , ---------------------- ------------------------------ 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