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APPLICATION FOR, SANITATION PERMIT Permit No. ell (Complete in Duplicate) Date issued / ! �-T'_____- - Applica{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. k JOB ADDRESS AND LOCATION/__- _j --------------------- - - - f -- ------ ---- -- -- -------------------------- -------- ---------------------------------- Owner's Name - + = Phone -al ti. Address------- �.!__P_(i0---- r ' Contractor's Name - , ,�[. :cam 4------ ------ PhoneJ�__46_,FA_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Lot size _____ _ D_`_- _._/-.2..________________ - Number of bedrooms __ ___-- Number of baths _Z �._ Water Supply: 'Public system R_1_C`cmmunity-system ❑ Private ❑ Depth to Water Table A Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9--H'ardpan E] Previous Application Made: Yes ❑ . No New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: `��-----w- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T nk: Distance from nearest well ------------- --- Distance from foundation -------------------- Material ______--_.-____________________..___-___________. No. of compartments --------------------------:Size ------------------------------- Liquid depth -------------------------- Capacity----------------------- osal Field'` Distance from nearest well -------------- ___.Distance from foundation ----- _--------------- Distance to nearest lot line __--________-____ Number of .lines----------------------------------- Length of each line ------------------------------ Width of trench ----------------------------------- !! Type of filter material ----------- --------------- Depth of filter material ------------------------ Total length_________________________________________ Seepage Pit: Distance to nearest well__N_v_,.it____Disfance from foundation___;/_Q_'_-'Di apnte to nearest lot line_____f d Number of pits__ ------------ - ------ Lining materia; _� _-Size: Diameter: ----------- Depth___ ,(_-____-____-______ Cesspool: Distance from nearest well ----------------- Distance.from foundation --- _---- ---_-_:____.Lining material--.. ---------------------------------- ❑ Size.: Diameter--------- -------------- =-------- Depth -------------: -.------------------ ----------------- Liquid Capacity---------------------- ---•-gals. Privy:E Distancerom,nearest well___________________________________________' _ -._Distance from nearest building---__________-________---_--_----_-_---. ❑ -Distance to nearest lot lire__'-"______'__-__ --- �- -- ------- 4_1 --------------• -------------•--------- Re cdeling 'and/or repairi (descriL�o):_- +n. _ �s „----- 71,0----- ---------- ----•------ ------- ----- - ----.... __...,---- i ---------------------------------------------------•-------------------------- : -------------------------------- --------------•-------------------------•---•--•-----------------------•--------------- --------- 11hereby certify that l have prepared this application and 'that the work will be done in accordance with San Joaquin County ordinancesf5#a aws, and rules an a ulation_s of the San Joaquin Local Health District. (Signed _ ---- ------- j -----=-------------------------- r Contractor) tgY• ---------------•-----------------•------------------- ', _-..- (Tltlea - "] [Plot plan, showing size - of lot, location of system in relation o wells, buildings, etc., can -be pla ed_on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------- DATE------------------ - - - - -- ---- REVIEWED BY =--------------------- DATE---•------------- -------------•----------- ---- BUILDING PERMIT ISSUED--------------------=----------------------------------------•--------------------------------.----- DATE Alterations and/or recommendations----------------------•----------'------------------------------------------•---------------------------•---•- _ E i 9 fi ___.-.-___`_______________________________________________ ________ t�._______-_-__---_____---__,-_-_________--________________--______--__-_____-__--__-_____-_--______-„________--________--__-_-_____-_____________._.__.-_ i FINAL INSPECTION -BY:.-_K;=_ BY: --'= 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 Revised W-2100