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f APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _l Date Issued � s_ /h, Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descKreK�) This application is made in compliance with County Ordinance No. 549. • � ------------------------------------------ - S7O C-/ 01./JOB ADDRESS AND LOCATION--------------A—"o -----------4;1_ ---------- -<--___ __ --------- Owne'r's Name------------- t------------------------- -----•---- _ ._._ ----- ---- ---- - --- . _ Phone------------------------------------ Address--------------- -•-•---------------------------•---Address--------------- - -------------------- ------- Contractor's s ' }----------------------------- Contractor's Name------- -------•------- s j ------------------------------------------------ Phone----------------------------------- k will server ;Residence � Apartm net House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms .-------- Number of baths -------- Lot size ------------------_________________-_________________-.__ Water Supply: Public'h stem ❑ Community system ❑ Private ❑ Depth'to Water Table -------- ft. .r Character of soil to'a depth of 3 feet: Sand.L] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ 'Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑! No ❑ New Construction: Yes ❑ Na ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septicfanVor cesspool permitted if publics ewer is available within 200 feet.) Septic Tank: Distance from nearest well-----Sb--------Distance from foundation-----(0-----------Material____ -4{P____________________________ No of compartments--------_-21-n-A----------Size---- ........Liquid depth------til"----------------Capacity__.-Tf--4D:_�_ „ 3 Disposal Field: Distance from nearest well_____S�--------Distance from foundation----;L0..........Distance to nearest lot line..... -___--__- •� Number of lines___________ �---•--_ -'--_Length of each line---,la. -�a _ a..Width of trench Type of filtermateriaL,__ •--------__-- of filter material----18 .............Total length___.. ------------------- - w, Seepage Pit: pistance�to nearest well..________.,__.___'_._Distance from foundation--------------------- to nearer'lot e______________:__ ❑ Number of pits--.----t-------------7C,ning material----------------------Size: Diameter-'-------------------- Depth---- -___---- 6 Cesspool: Distance from nearest well_.__-____i___.=_Distance froom foundation___________ + ..Lining material______________________________.___ ❑ Size: Diameter- --------------------------- 0 p)epth-------------------•---------------:---- : " Liquid Capacity------ ---------------------gals. I. Privy:.` Distance from nearest well--------------------- - Distance from nearest budding ❑ '- Distance-to nearest`lot_''line_" _ - -------------------------------------------------•••T----- ------------- ----- ------------- I Remodeling and/or repairing (describe)--------------------------------------------------------------------------------- '- f F _______________________________________j__-________________....____-__-___-.._..___..__-_--_--.------_----_---.-_-_•________.___________...__....__.______________-___________________.___..._..._-___________'____________. r { --------------------------------------------------------------_---______________________________________________________________________________________________________________t_____.___---_____-_____________-___-__.--•--- 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 iegulations of the SSan� Joaquin Local Health District. ' Si ned - - ..._.- ( g )---------K:eE:�5_ -- -- - ---- ---- ---- --------------------------------------•--------------------.(Owner and/or Contractor) Plot Ian. showin = f =-----------•-------------------------=---------------------------------------------:..(Title)--------------------------------------•--- -------------------- _ $ :----------------- ( p g size" of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). A— F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- DATE----_----------- REVIEWEDBY-----------•------------ -------------------•--------------------------------------------------------•---------------------- DATE BUILDING PERMIT ISSUED---------------------------------------------------•---------------------------=------------ ....... DATE.------------------------------- Alterations and/or recommendations: -------------------------- •---------------------- ---------- ----------------------------------------------------------- a ---s€gam - 1 � � ::_.. �5v _________________._______________-.-._________-______._-_______________._________-__.____.______________.__________._____________-_------.____------__._______________._____________....___..____--_-__-__.________________-- ---------------------------------------------------____________________ -__ -_ ___________________---------------____ _______________________-----------------____________ FINAL INSPECTION BY::... I -E---'--------------------------•----. Date----------------------------------------------"----------------------------- SAN ---- ----_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