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DANAPPLICATION FOR SANITATION PERMIT Permit Na_9--/V__f�.... (Complete in Duplicate) / I �� Date Issued * r. Application is ereby made to the San Joaquin Local Health District for a permit to const1uct and 3install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--- - -� -------- _.-- Owner's Name---------�- .. .... . -------- ------ ------•----- -- ------------------ -------------------'----- - Phone------------------------------------ Address--------------- -----------------------------------Address-----------------------------------------•------- Contractor's Name `---------------------•------------------•------------------------------------- ------------------- ------- Phone----------------------------------- Installafion will serve: Residence x Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Q Other ❑ ~` Number of living units:/______ Number of bedrooms -__ Number of baths __1___ Lot size _ _ ' ______________________:___ Water Supply: Public system Df 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 public sewer is available within 200 feet.) Septic Tank: Distance from nearest well __Distance from foundation__/Q____.:.__.Material____6" ------------------ No. -__________ __ . No. of compartments �___ _________Size__ ___ _____.__-Liquid depth____- _l - -- _ :___CaPacitY- -O-0__ Disposal Field: Distance from nearest well _.Distance from foundation-/ _-_-----._-Distance to nearest lot line_c,�_ ....... Number of lines____,3________________f______Length of each line_3�} 34-110_.Width of trench__,:_ _ Type of filter material--- -------Depth of filter material-___.P` _ To}al lengthf_e '_ ......... Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line________-_-____- ❑ Number of pits----------------------Lining material-------------:---------Size: Diameter------------------------Dept h------------------------_-------- Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material-------------------------------------- El Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------.___--___-__-_. ❑ Distance to nearest lot line------------------------------------------------------------------ Remodelingand/or 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, and rules and regulations of the San Joaquin Local Health District. d _-� (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----- -------- _ REVIEWEDBY------------------------------------------ ----------------- ---------------------------------------- DATE `- --------------- BUILDING PERMIT ISSUED--------------------- ---------------------------------------- -------------------------------------- DATE -Atte atia and/or recd mendations:_ --------------------- ---------- V ____ T_ __ _ ----- -- ---- '�---- 5 =/= __7------ ---- - --- -------- - �.-----� � - - - -- --=/��'- — - 'tom ------ L - ---------- y- / � > _ 4f^ ------------------`----'-------------'--------- --------- = �--- - ------ ------- ----------- ---------------=--- ---------------------- 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 B-51 Revised W-2100 f