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Duplicate) Date issued 3-z---9 �- APPLICATION FOR SANITATION PERMIT Permit No. ____-.._ 9-4- (Complete (Complete in Dup /�,3 S ''- 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 DLLOCATION... - ----- - - -------------------------------------------------------------------------- Owner's Name....--- Aw T—W--+----- --- Phone f Address------------ *#1--D__5--- ---- _ _. Contractor's Name-------- ------ ------- -- ------------- Installation -----------Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___J___ Number of bedrooms _ --- Number of baths _-I___ Lot size -----7� -- ----4P_ ___--_-__--____-__ Wafer 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 2eHardpan I] Previous Application Made: Yw,E] 'No 'Jew Construction: Yes to ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) e Septic nk: Distance from nearest well_1jkA_rr%.,Uistance from foundation---/ ________.Mater ) _� __ __ No. of compartments.....'..�--------------Size__Z.](___�_�_�__Liquid depth_____ ____Capacity______ �___ Dis os Field: Distance from nearest well__-Y e, r- ..Distance from foundation._--_` .--.--_-Distance to nearest lot line p �l Number of lines_________________ ____ ____Length of each line------- p_�___________.Width of trench______ -- ------------ Type of filter material_j___R�„�_Depth of filter material___ ° '_________Total length_________ __. __________________ �,, Seepage Pit: Distance to nearest well----------------------Distance from foundation.........-_.._..___.Distance to nearest lot line----------------- `� F1Number of pits----------------------Lining material-----------------------Size: Diameter---_-------------------.Depth---------------------__ _ �:' Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________._.________________--------- l --Size: Diameter--------------------------------------De th----------------------------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------............................ ._._. ❑ Distance to nearest lot line------------------------------------------------------A-------- --------------------------------------------------------------------- Remodeling and/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 he San Joaquin Local Health District. --- (Signed)------------ --- ------------ q------ - - -- --- - l- - -------------�------------"-'- -- --------------------------(O er and/or ontractor] By------- (Title) i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- - -- --- ---- ------------- --------------------- ------- = DATE--------- --}- � � - --------- REVIEWED BY----------------------------------------------- I� - ------------------------------ ----- ---�--------------------.------------ DATE-=-------------�----�------- --------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- 4 I Alterations and/or recommendations:-- --- ---- ------------------- - --------------------- ----------------- - ------------------------------------------------------------------- i ------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------- r ------------ ------------------------------------ --- ----------------------------------------------------------------------------------------------------•---------------------------------------------- ---------------------------------------------------------------------------- - ---- - ----------------------------------------------------------- --------------------------------- -------------------------------------------------------------------------- FINAL INSPECTION BY: --------- Date----- ° --------------- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT j 130 Soufh American S+reef 300 Wes+ 0A S+reef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California w ES-9-2M B-51 Revised W-2100