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r� APPLICATION FOR SANITATION PERMIT Permit No.j. D J ] (Complete in Duplicate) Date issued Application is here 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 ANDCATI N_________e� ------------- ✓; --------- ----------I/,,,/-------4------------------------------------- ---------------------e Owner's Name------------- -----• - - - -- ---------- -- ----------------------------------------- -- Phone------------------------------------ Address-------------------•- 61 0 � � _ -R-------------------- -- --- -- - - ---------------- ------- .� / Contractor's Name Q '------------------- Phone ? Installation will serve: Residence finent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j____ mber of bedrooms --- Number of baths ---.l__ Lot size ____ih_a i '_ -________-_-.__ Water Supply: Public system Community system ❑ ,Private'❑ Depth to Water Tab[ 4 ft. ` Character of soil to a depth of 3 feet: Sand ;Gravel E] Sandy Loam ❑ Clay Loam E] Clay E] Adobe ardpan ❑ Pravious Application Made: Yes ❑ No New Construction: Yes a--No ❑ -V ,TYPE'OF INSTALLATION AND SPECIFICATIONS: W (No tic tank or cesspool permitted if public sew r is available within 200 feet.) # W Septic nk: Distance from nearest wel l Distance from foundation--t -----------Material _ 1a____._______________ No, of compartments__ _ e____ Liquid de th__ _f__� � CapacitY---_�__ �f-/ DisDiOance From nearest weiVj-l� istance from foundation--/��___-Distance to nearest of line---?O-- ---_-_-_-_ Number of lines___ ______�_� Length of each line----&_Q------------------.Width of trench- -- --- ------ --.__s_-- ?-n- Type of filter material_ - _Q ___Depth of filter material__/k------------Total length______' _ - } Seepage Pit: Distance to nearest, well_____________________Distance from foundation--------------__.-..Distance to nearest lot line_______________ ❑ Number of pits------'--------------Lining ma_ferial-----------------------Size: Diameter_-- --------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_._______--_____---_-------__-______- Size: Diameter____________________________ __ ___Dep th_-__---_________ _---_.-Liquid,Capacitys ______ . _ Privy: Distance from nearest well------- __________________________Distance from +nearest building------------------------------------------ ❑ Distance to nearest lot line- . -- ------------- --------- Remodeling and/or repairing (describe)---------- --- -- - C----- -----a--- ------------------------------------ --------------------------------------------------------------- ---•-------------------- = -A.-------- �--------•6--• � � = ------------ � t � ------------- ----------- --------- -- ----------- ,c _ < -------------------Ae�- --- ---" -= -•--------------------- ------------------------------------------------- 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. )6_1114 - --�l�f ( / I (Signed).•------• .----- �•�l --•------------- ---------- - __Own and Contractor B Y " ' --------------------------------------------------------------------{Title} (Plot plan, showing size of lot, location of^system in relatio4 to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--(:?f.Z - - -------------------------------------- -------------------------------- ------ DATE-'k--- -- r-----=- --- ----------------- REVIEWED BY -------- - - - -------------- ------------------------------------------ DATE---- --------- ` w' BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--- ---R��------- ---- Alterations and/or recommendations:------------------------------------------ ----------------------•---•----------------------•---------•�------- ----------------------------------------------------•----------------------------------------------------------------------•-•-----------------------------------•-----••-----------------------------•--------------------- -----•-•-----------------------------------------•---•---------------------------_------------------------------------------•------------...--------------------------------------------------------------------------------- ------------------ -----------•--- FINAL INSPECTION BY------ --------- J! ---.----------_ 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 10-52 Revised W-2100