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e i _ ( APPLICATION FOR SANITATION PERMIT Permit NocA_A--- _ t' ? (Complete in Duplicate) Date Issued _�' 1��,5� Application i�h eb made to the San J Q('�'��N Y Joaquin Local Health District for a permit to construct and in�T511'fMf:'Vbdl��Ii described. This application is made in compliance with County Ordin ce No. 549. IC i JOB ADDRESS AND L CATION____.____%7.1 - _•_____-___ -------------•------------------------------------------------ Owner's Name__________ --------------- Phone Address------------------' Y-7 --- Contractor's Name___________ _ ------- ----------------------------------- ------------------------ -----------------_---- ---------------------_---- _____-- - ------------- --------------- Phone----------------- - i Installation will serve: Residence �A--artment House ❑ Commercial Trailer Court ❑ ❑ Motel ❑ Other ❑ Number of living units: __� Number of bedrooms,___ Number of baths _ �_ '�l Q � .�___ Lot size _� _ ----------------------------------- Character ________ _•_ Water Supply: Public system [Community system ❑ Private ❑ • Depth to Water Table __t- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No t New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Z , Se t' Tank: Distance from nearest well__-__-Distance from foundation_/6__'__ ____ y%j' Material = No. of compartments---------�1 -______-____Size___�_�C__ _)(_ -_------Liquid depth Capacity- 6 P � - q P P tY--- Disposal Field: Distance from nearest well Distance from foundation__l_0-_______-___Distance to nearest lot line_�..5-__-___.. Number of lines________ _____ _______________Length of each line___f�'� ___________.Width of trench_____'.�___Y._` r. Type of filter material___. ____Depth of filter material-----------------------Total length__________________ Seepage Pit: Distance to nearest well------------ ----------Distance from foundation--------------------Distance to nearest lot line_______________ ❑ Number of pits----------------------Lining material----------------- Cesspool: Distance from nearest well_______________ ------Size: Diameter------------------------Depth-------------------------------- ❑ Size: Diameter----------- - __Distance from foundation______________-__.Lining material-------------------------------------- Privy: Distance from nearest well_ r ---------------------------Depth----------------------------- -- -- ------------_Liquid CapacitY- --------- -----------gals. ______ --------------------------------Distance from nearest building Distance to nearest lot line------------------- Remodeling and/or repairing (describe)__________--------------- _-_------------------- _ _----_-_------_---•---_------•-_' ---- 2 ---------------- ---- --------------------- -- ---•------------------------------------ ---------------------------------------------------- ------ - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. (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------------------------------------------------------------ ------------ BY__ ---- - - f ----- ------ DATE-- ,BUILDING PERMIT IS __ �-��.:_____________ ---------------------------------------------------------- ------- - DATE------------------------------------------- ------------------------------------ A terations and/or recommendations:______._ -------------------------- -------- ------------------------------------------------------------ -- ---- ------------- ----------------------------------------------------- 1 a..n ------ ------- --------------------- - - ----------------- -- ------------------- _--- ------------------ - ---- ------------------------------------------------- ---------- --ix. ------------------------ --- 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 8-51 Revised W-2100