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5 �� APPLICATION FOR SANITATION PERMIT Permit No_ ________________________ (Complete in Duplicate) / Date Issued/a�0_��,t 7"' 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 ©FJinan No. 549, JOB ADDRESS ALOCATION... t1.__v__t' _. !" - u' ------------- -------- Owner's Name _.C7-_-1 =� i Address-- `� �{�� •---------------------- - Contractor's Name-- - i''1�J-�- Phone------------------------------•--- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other s❑ Number of living units: _;�_____ Number of bedrooms _t__ Number of baths _/___ Lot size ___��.�-- -��-�----------------_---- i Water Supply: Public system Community system ❑ Private'❑ 'Depth to Water Table,__...__- ft. Character of soil to a depth of 3 feet: *;Sand Gravel Sandy Loam ❑ Clay Loam [] Clay Adobe [Hardpan ❑ Previous Application Made: Yes E] No [ E] [INew Construction: Yes Ee No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feetp) Se tic ank: Distance from nearest wel Distarlcp fro oun�. o ._-___ Mater _______ p /T -- ---------- -I, p tY- -- � [n+j No. of compartments_____.. ize __c��_ _ _Liquidepth __ __-�___.___.___Ca aci -- _ Disposall"'Field: Distance from nearest well 440 Distance from founds io �e-_ _iD stance to nearest lot li -------------- Seepage ' _, +� f� Number of lines---------- Length of each line__________._ �c_'.__ .Width of trench__.___/�t__- - �1, --------- -- Type of filter materia+rq �id�___ _ -----Depth of filter material_______--��-- ____Total length____..------�� -.._ Seepage Pit: Distance to nearest well.-_____A`__-_-_-_-Distance'from foundation___.___."..._..Distance to nearest lot line_________________ ❑ {Number of pits----------------------Lining materia;---s_------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest wel!________-;,._____Distance from foundation-------------------.Lining material___.____..____.._____________________ ❑ Size: Diameter---------------------- ---- - ------Depth--- ---------------------------------------------Liquid Capacity----------------------------gals. Q Privy: Distance from nearest well..._------_---------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line------------------------------------------ Remodeling and/or repairing (describe :-- ---------------------------- - - --•-----------------••--•--•------------ •--------------------------------------------------------------------- ----------------•----•---•--•-----------------------•--------------- --------------•-------------------------- ----------------------•---------------••----------------------------•------•--------------------------------- ----- ------------------------•-----•---------------•------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County e, ordinances, fi to laws, and rules andFregulations of the San Joaquin Local Health District. r i (Signed)__ _ Pt's _________ Owner and/or Contractor P------ --------•------ --- ------ -------- ---•-----•- -- -------------------- By:.--•---------------------------------------------------- I--------------------------------`------_--------~ •`------------(Title)---------------------------------------------------------------- (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- € ----------------I--------------- DATE . ----------- ---------- REVIEWEDBY---------------------------- ------------------------------------------------------------------------ ----- DATE__. BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---- c - Alterations and/or recommendations:-------------- ------------------------- ------------------------------------------------------ ...... ----------------------------------------------- ---------- ------------------------------------•------ ------------------------- •-------•---------------------------------------------------------------•-----------•------- -------------------------------------------- •-----------------------•------------------------•---•--•---------------------------------------- FINAL INSPECTION BY: ------ ---lo ------------------------------------------ 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