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y APPLICATION .FOR SANITATION PERMIT Permit No. -w f-fQ----------- i (Complete in. Duplicate) Date Issued --hlt 6__ _ 3 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 Cou t Ordinance No. 549. JOB ADDRESS AN LOCATI .N__!._ ---- -- �r-.P - - ------- ------------------ --------------------------------------- Owner's Name ;r -------- Phone------------------------------------ . . • ---.-x--- ---- -- Address----------------- ...- -------_.-----------------------------------•-------------------------------------------- ----•-------------•-----------------------------•--------- Contractor's Name---------------- _ _ _____ ______________ A _____________________________________________________________ ------ Phone----------------------------------- _.-- ._ 4 Installation will serve: Residence partment House ❑ Comm`ercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ____ Number of bedrooms ___ _ fVumber of baths ._�_-. Lot size sG_ -------------- u Water Supply: Public system ❑ Community system ❑ Private �epth.to Water.Table ________ ft. Character of soil to a depth of 3 feet: Sand E] G vel'❑ Sandy Loam [I Clay Loam El Clay ❑ Adobe Rg ❑ Previous Application Made: Yes ❑ No New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s wer is available within 200 feet.) _ Q I Septic Tank: Distance from nearest well_..-0-- -Distance from foundation----�__p--------.Material__ -- y-S� -- (� swor No. of compartments-------4 Size-�: 1\ ' - --t`-"-'----Liquid depth---- r Capacity - W 1, { Disposal Field: Distance from nearest weh__ 0__Distance from found do f - Distance to nearest lot 'ne_ `" x Number of lines--------- -- ------ -Length of each lin _ ._.Width of trench-_r_�____ .�- 1�-------Total length-------•-- -- - Type of filter materia,1- -__�. Depth of_filter material- - _ Q . 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--------- ------- _.__.. Sizc:,Diameter- --- : ---= ----- --Depth----- -" --- - --t -Llquid`CT apacity J " r gals. .., 7--- -.mss.= ,.,. ,. �• _. Privy: 'Distance from nearest well---------------------- -------------- ------- Distance from nearest building____.... ------._ Z, ❑ Distance to nearest lot line------------- ------------------------------------------------------------------------------------------------------- ---------------- Remodeling -------- ------ Remodeling and/or repairing (desc7ribe):------- --- ---------- -- -------------------------------•-------------------•---------------------- ---k{ l -----------^----------'-------'----------------------------------------------------------------- -- --- -------- - -- --------- - I hereby certify that I have prepared this 42 and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reg------ tis of the San Joaquin Local Health District. (Signed ------. - -- --- {Owner and/or Contractor) --------------------------------------------------------------- (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 4 --------------------------------- DATE .-. r > REVIEWEDBY--------------------------------}------------------------------------ -- -------------------------------------------- -- DATE------------------------------- --------------------------- BUILDING PERMIT ISSUED--------:::� ----------- --------- --- DATE------------------------------------------------------------- -�g— Alterations and/or recommendations-_/- --- ------- 41-' �` --�'""� _ - - '-----------Y-f��• �' -- - ----------------------------------- -------------------------------------------------------- ------- } j 7a, ---- FINAL INSPECTION :------ ------------------------------------------ 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