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PPLICATION FOR SANITATION PERMIT Permit No. 6 f ------------- (Complete in in Duplicate), - -� -- Date Issued Applic'&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 Akj-ATION --__ cS hI '---- ---- t--•- - ==- t----------------------- -- -- - ------------------ ---- Owner's Name_____ 's' �j JI! --------------- -- n Fa•(.! ` Address------ 1---------�i _ '�' , ------ An___ Contractor's Name____! -_-- � ' Q —a ----------- - - ---------- ----=-------------..__ `-- --- Installation will serve:. Residence 4�artment House Commercial $ "'N ❑ ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:lj____ Nurnber of bedroom; _A� Number of baths _____ Lot size4---------- ---a Water Supply: Public-'rsystem ACOmmunify system 'E] Private ❑ Depth to Water Table 36- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑� Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Now Construction: Yes k Ivo n TYPE OF INSTALLATION AND SPECIFICATIONS: o (No septic Tank'or cesspool parmifted if public sewer is available within 200 feet.)� r r Septic Tank: aDistance from nearest well#91ZDistan e from foundation---- ___r..__.Material____ d+ - �Le_ fr ------' No; of compartments---------�_---.____Size_47__X__�_Q-------Liquid depth_ __- - . itac Cap y____ C�---- - ` Disposal Field: Distance from nearest welloP& Distance from foundation-----11--°___.Distance to nearest lot line___.'-*--_- t Length of each line---------*_4 e---.----.Width of trench- -may r '-- [f}� Number of lines_____________ Type of filter material'_- 15(----Depth of filter material-----/ -"------Total length-------ZQ- .-,--____y-_---- j 3 , Seepage Pit:, Distance to nearest:well- _Distance from�fondafion____-�4----____.Distance to nearest lot line---s1____.-__, Number of pits._______-----------Uning materia -_Size: Diameter----t2C-----_---__-Depth--- „ ?_'----=-------- Cesspool: Distance fi•orn nearest well-----------------Distance fron'i foundation--------------_.__..Lining material----------------- _________--__•_____ ❑ Size: Diameter -------------- ----------Depth---------------------------------------------- -----Liquid Capacity----------------------------gals: Privy: , Distance from nearest wefl_ ------------- _ -----------------------------_Distance from nearest building ° ' Distance to nearesf1lof-line:_.-_- ----------------------------------- --w--------------- }------ ---------------------•------------------------------------- -- Remodeling and/or repairing (describe):-----,r---- -------------------------------------------- ( ------- •-----------•--•-----•--------------------------------------- --------------------------------------------I ------------------=------ --------------------------------------- -----------------------_----------------------------------------------------------------- -------_____________•..-_____-_.....________--____-____..._______-___-___.___________.___._______...________._______-_______________._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. t t (Signed)---- - -•-----°--• •--• BY: j - -Contractor) f Y• j ---[Title}__ (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY. APPLICATION ACCEPTED BY--------------------------------------------------- - -- DATE_---- -- -- - ,�•••-- �- ------------=----------- - REVIEWEDBY------------------------------------------ ------------- - ------ DATE----- ---- -- BUILDING PERMIT ISSUED - ----------- --------------------------------- • ---------- DATE Alterations and/or recommendations:--------•------------------- - ' -•-----•---•-------------------•--------------------•-------...__.-.-------------------------------------------------------•-------------•--••-------------------- •----------•-- --•------------------------•---------•--- ------------•-----•-•----•---------------•-----------------------------------------•--------•_--•-----f——------------------ -------------------------- ---------------•---------------------------------------- -- ----------------------------------- ---------------------------------------------- : . -• ------- FINAL WSPECTION -BY:........... ... �`' ---•---�---- ----•--------------------------- Date-=----- ---------- '-�----- -• � ---- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street ;f Stockton, California Lodi, California Manteca, California Tracy, California / .SES 9--•2M Revised W-2100 - i