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r' APPLICATION FOR SANITATION P �D z ERMIT Permit No. (Complete in Duplicate) Date Issued ___�1-�S 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 complia with County Ordinance Poi1549.� JOB ADDRESS TIO c � ` ` " e r i f- L i i r° Owner's Name____ - t�_ ------ -- ----- ------ �^ -- . -------------------------------- ------------- Phone Address------------ -------------------------------"---------------------------------------------------- Contractor's Name... ... .. .... . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ M'-yolel ❑ Other ❑ Number of living units: _._�__ Number of bedrooms --- _ Number of baths "_./___ Lot size v_.� c5`_ ------•---------------------------------- Water Supply: Public system Community system ❑ Private [I Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: San Gravel E] Sandy Loam Clay Loam E] Clay El Adobe�ardpan ❑ 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 fee#.) Septic ank: Distance from nearest well__„___ 2----Distan ound io 7t p ri(1 Mater al�_ �' = No. of compartments --------7-----Size------ Liquid,depth--------- - ------- Dispos Field: Distance from nearest well------Distance from founds ion/#' :�_— _-. istance to nearest lot lin _ Number of lines___-----_ --------- Type � ------_____ .Length of each line_.' � •• " _ ------------- ---- 'X�-`-'-�- --o� _.Width of trench_.______ _ ___ _________ T e of filter materi ,/ .'� rf Yp r-- _:._ Llspth of filter material___.__ T _._.____._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__._____.__.___._______._________ - Privy: Distance from clearest well Size: Diameter-----------------------------------Depth---------------------•------------------------------ Liquid Capacity---------------------:------gals. _______________________________ __"______-___._Distance from nearest building------------------------------------------ Distance to nearest lot line.-------------- 1 Remodel in and ' r 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 laws, arc rums and egulations of the San Joaquin Local Health District. .. (Signed)--- t=- '=-----=-----=--=-----t---------- -------- ------ ---------- ------(Owner and/or Contractor) By:------------------ ---- -------- I-----------------------------------------------------(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 -------------------- ----------------------------------------------------------------- REVIEWED BY------------ -.. DATE. ------------------------------------------------------------------------------- BUILDING PERMIT ISSUED DATE =------------•--------------------- ----------------- DATE. Alterations and/or recommendations:_______.____________.__._.__.______ ------------------------------------------------------------------------------------------ ---------------------------- ---•--"---- ------------------------- ----- ------------------- FINAL INSPECTION BY:------------ G " K� `"' ----------- Date / /C J`,j" SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M ; I Revised W-2100