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APPLICATION FOR SANITATION PERMIT Permit No. -- g.G- --------- Ll 2/1 (Complete in Duplicate) -� Date Issued -67: 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. 5497.E JOB ADDRESS AND 1ILOCATION-----_«� ------ )•-------E ---4-6 Owner's Name x- � - ------------------------------------------------------------------------------------- Address "°-- --------- -------------------------------------------------••-----------------•--------------------------------------------------__._.. Contractor's Name-------- '!'{ -----1 M .---------------------------------------------------------------------------------- Phone-.3 k--t ------------- i Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A,___ Number of bedrooms __ __ Number of baths j____ Lot size ------- ________________________ Water Supply: Public system M Community system ❑ Private ❑ Depth to Water Table ___7_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: Yes ❑ No K New Construction: Yes D4 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 founclation___._��_______--Material-------I '�_0-6-val __a___----------- ® No. of compartments_______.__ L----------- q p Q_�9RW_ -____--Size-__-_---� �__Li-X_��- uid depth - k Disposal Field: Distance from nearest well---—-------Distance from foundation----AF---------Distance to nearest lot line------ � Length of each line-_ -- -_____ �Number of lines---------------�----___-- -- g '_--�3?_:__--.Width of trench--------v_Z__�___-,---------____-- Type of filter material/ 11MLk Depth of filter material------1P_.'.......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-__________-___--____-____-_-_____. r}i ❑ Size: Diameter------- ------------------------------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. f Priv Distance from nearest well----_---------------.--_ Y• -------------------------------Distance-from nearest wilding---------------------------------=------ + i ❑ Distance to nearest lot line------------------- --------------------------------------------------------------- , Remodeling and/or repairing (describe]=--------------A)gA--j--------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------•------------------------- ----=----------------------------------- -----------•---------------------------------------- -------------------------------------------------------------------I----------------------•--------------------------I------------------------------------------------------------------------------------------------------- 1 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. (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- REVIEWED ATE REVIEWED BY------------------------•------------------ -------Y---+___ --- -- --- --------------------------•--------- DATE------ -------------- - BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------- ` Alterations and/or recommendations:------------------------- --------------------------------------------------------------------------------------:-------•-••----•-------------------------- --------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------- --------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ -------------- ------------------------------------------------------------------------- ------------•---------------•-------- --------------------------------- r - FINAL INSPECTION BY------------V - - ---- -------------- Date------------- -------------•-----•---•---•--••-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M 8.51 Revised W-2100