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�6 5 APPLICATION FOR SANITATION PERMIT Permit "No. _____ v�_,-S Y 2-4 (Complete in Duplicate)1 Date Issued 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. ESJOB ADDRESS AND LOCATION------------ &�_____________�•_ Ry_ Owner's Name------------------ _. Q ------------- Phone------------------- ----- Address-------------------------------- --- - --------------------------------- Contractor's Name------------------ '---I------------------7 Phone-.----_----------------- Installation will serve: Residence W Apartment House Commercial P ❑ ❑ Trailer Court ❑ Motel ❑ Other l.f Number of living units: .------- Numberf bedrooms -_ umber of baths - I--_ Number y f ---• Lot size --------- '--- ------- ---- ---- --------------------• �1 Water Supply: 'laublic_ osystem A Community system ❑ Private.❑ Depth to Water Table -------- ft. 4 Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam Clay.Loam E] Clay E] Adobe❑ Hardpan ❑ , Previous Application Made: Yes ❑ No (R New Construction: Yes V No I] TYPE OF INSTALLATION AND SPECIFICATIONS: 0 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) bI I Septic Tank: Distance from nearest welk___."�"":_=_Distance from foundation-----1-Q- Material--------1jl� No. of com artments___________ Liquid depth - _ _V-------------- 44) - ------. -_CaPacitY---_ �_._ Disposal ,Field: Distance from nearest well------_____------.Distance from foundation____ • Distance to nearest lot lm�________________ Number of lines--------------y_r---------------Length of each line�1-_:gA-30 o SWidth of trench___-.--,may!_____- .__.__--•_-- • Type of filter material------)fes_ ----Depth of filter material_______1r_�`.______Total length_____/M--�---_--___- ------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- E Number'of pits----------------------Lining material-----------------------Size: Diameter-----_-----------------Depth--------------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------_______.___ Lining material _ - _______________________-_----- i ❑ Size: Diameter------------------------------------- Qepth ----- -----------------------------------------------------Liquid ------ ---------- gals. } Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______________________-_-_ ------------- ❑ Distance to nearest lot line------------------------------------------------- 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 rul sd regulations of the San Joaquin Local Health District. (Signed) ----------------------•- -- ------ -----(Owner and/or Contractor) 6- 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 DATE - _ -� REVIEWED BY ------------ ----- - 2 - •- ------------------ BUILDING PERMIT 1SSUED---------------------------------------------- ---------- -- - ------------------- -- ------- DATE-------------- •-- --------- A terations and/or recommendations-------------------------------------------- •------------------------------------------- ------- -----------------------------------------------------••-------•-------------------------------------------------------------------------------------------=-------------------------•----------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- - _______________ _____________________________________ _„ _ FINAL INSPECTION BY: -------------------------------- Date-------- -- ---- - SAN JOAQUIN LOCAL HEALTH DISTRICT '1 130 South Amer w Street 300 West Oak S+rest 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-SI Revised W-2100