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\ APPLICATION FOR SANITATION PERMIT Permit No6:'... .�a.. .. (Complete in Duplicate) Date Issued Applica4-ion 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 LOCATION----•--��/--- .� _____________ ..,r ___,� --- - ----------------------- Owner's Name-------- ------------ �, '---------------- -----------------• - ----------------- Phoner '!�M-7-.. Address--------- r��° ..... ----------------•--•--------------•--------------------------------- _.. ------------------------------. Contractor's Name......... ------------------------------------------------------------------------------------------------- Phone•-_ y-G -.z Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other Number of living units: . ___ Number of bedrooms .3__. Number of baths Z... Lot size ..... ......................... Water Supply: Public system Ert-ommunity system ❑ Private ❑ Depth to Water Table .1$___Sft. Character of soil to a depth of 3 feet: Sana❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes FA- o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well�'''e'.Distance from foundation....A--------.Material-----ADD-C'__ No. of compartments-_ __--.-02__-_-_____-_-._Size__5�"kiZ0.'.._.._.Liquid depth___��__.______-_-Capacity.... 08` ' Disposal ield: Distance from nearest well_Distance from foundation....av___._._.Distance to nearest lot line-______......._ Number of lines------- _____________Length of each line....1AA..._______-------Width of trench____, _ _�.___._._. . Type of filter material__S1_ Q -----Depth of filter material____.Z_ -.._______Total length_______la_!�........................ Seepage Pit: Distance to nearest well--- Distance from foundation..-.3!�........Distance to nearest lot line........... .- (� Number of pits-----Z------------Lining mate ria l.A-MR�---Size: Diameter.._.._� ------.Depth------!_s'................. Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material-------------------------------------- NA ❑ Size: Diameter--------------------------------------Depth---------------------------•----- ------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well __:_______------------------------------------Distance from nearest building__'__._--___---______-_-.--.----_------ ❑ Distance to nearest lot line----------------------------------------------------------------............................................ Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ ..............•-------•-------------------------------------•------------•--•--------------------------------------------------------------------------•-------------- -------------------•-----------------------------------------•-------------------------------------------------- ------------------•••.....-•------....----- 1 ----------------------- ------------------------------------------------------------------------------------------------•-_--•----•--------•-------• 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. (Signed)------- -°v`'tc - r' _. (Ow rand/or Contractor BY: ,t..2�� --- 2 (Title) ------. ..... . (Plot plan, showing size of lot, location of sys+e in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY--- ---- --------- ---- ------- =........................ DATE---- f -------- REVIEWED BY---------_------------------ ....... - --- --------- -----------------------r--------•--•------- ----........ DATE-------------------•--- BUILDINGPERMIT ISSUED.................................................................------------------------------------ DATE....................................... Alterations and/or recommendations______________ .._--_._-_-_--__.. --------------------------- --- --------•----- -•-•-•------•----••--•--------•--- ---------------------------------=--------------------------•------•---•-----•-------•------------------..................... ..................................... jr FINAL INSPECTION BY:............__.�..----Y`---x'11__ _......__ Date....__._._. -----------------------/-- --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100