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PerAPPLICATION FOR SANITATION PERMIT No. (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 AND LOCATIQN______.__.�-�-y,�- -- - -.-------- .3---ZI-----= Owner's Name `-- ----------------- hone -------------- Address------------------------------------- 7- ...... -r----�F f ------ Contractor's Name------- --- Phone - ------------------------------------------------- ------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other E]Number of living units: __._f_ Number of bedrooms ._2__ Number of baths ----/-- Lot size ----- _--X--- --------- ---------------- Water Supply: Public system ®' Community system ❑ Private ❑ Depth 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 publicsewer is available within 200 feet.) ` �/ v Septic Tank: Distance from nearest well .j t Distance from foundation____JQ_________.Mat��al______ - - = ¢-- No. of compartments------- Size----` r'4 ----Liquid depth------:�---------------- Capacity---ZQ---to----- Disposal Field: Distance from nearest well-----APA*.Distance from foundation___- e_o_______Distance to nearest lot f ] - ---- line..._-r_-_•_ ch_______21�_"_______________ Number of lines_________________'1---_-__-___-__Length of each line__-;__-__�_4__ ;__------Width oftren Type of filter material--------,y��---Depth of filter material----- Total length.----_---1-Zo------------------_-..- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- n 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--------------------------------------------•------------- ------------------------------- Remodeling and/or repairing (describe)_______________________ ------------•------- ----------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws, and rules and regulations of the San Joaquin Local Health District. f (Signed)---- - '"' ----------------------------•------------------------------------ _____________(Owner and/or Contractor) Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DE TM T USE QNLY APPLICATION ACCEPTED BY t r. ---•- . DATE------------- -- "-`-=--------------- REVIEWEDBY----------------------------- ------------------------------------ DATE-------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------- ------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------------------- - ---------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------- ------------------------------- ----------------------------------- -----------------------------------------------------------------------r--------------t---------------------------------- ^+ !. FINAL INSPECTION BY:---------- - - =` ------ Date------------------ --- ---- --- $ t - r 's 1� - - 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