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P APPLICATION FOR SANITATION PERM1 �, Yr 't No. . -�1----- (Complete in Duplicate) a}e Issued Y -- A lication is hereby made to tl�e an Joaquin Local Health District for a permit to construct and install the work herein described. Th is application is made in complluc.e with County Ordinance No. 549. JOB ADDRESS AN LOCATION---------- I__� ---------- - -----_. . ----- --------- Owner's Name---- � � ------ ----------------- --------------------- ---------- ----------- Phone.-- p -- Contractor's Name----(_j1!!`o-- .-)------•--•------ --- ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Number of bedrooms.__._ Number of baths _J_____ Lot size ------- ------------------------- Wafer -----------------------Water Supply: Public system VCommunify system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand Gravel E] ❑C Sandy Lo;"No Clay Loam lay E] Adobe - Hardpan E]Previous Application Made: Yes [:] No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted„if public sewer is available within 200 feet.) Septic ank: Distance from nearest well11 'r(1Vk`�`x"'Distance from found 'n__/_0- r .Materi `'� No. of compartments......z__.__ ______.Size_;-?_ 10.____1 __dLoiquld¢lepth._.___ Capacity____ _�i- Dispos field: DistanCE from nearest well • - Distance from foundation)V- '�Dstance to nearest lot line[_ 7T�a [i� Number of lines_________ ______- _____-___Length of each line------------- _ et_----.Width of trench----------- :.' � Type of filter materiel .A p g t------------- _ � Depth of filter matenaL__._ _ _ ---__Total length- ____ ----------------- _4 _______________ 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________..__________.___.______ ❑ 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):------------------------------------------------------------------------------------------------- ------------------------------------------------------- -----------•-----------•--•---•-------------------------------------•----------------------------------------------------------------------------•------------------- ------------------------------------------------------ ---------------------------------- ----- ------- ----------- -- ---------------- --------------------------------------------------------------------------------------------------- - -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, S e laws, and rules and regulations of the San Joaquin Local Health District. hl-,{Signed}-•___- -' ..� � sari.-f�----------------- - ---------------. --(Owner and/or Contractor) V By:----------------------------------------------------------------------------------------------------------------------------------------------------------(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-- - -------------------------- -------------- -- ---------- ---••--• ------------------- DATE _`------------- .. REVIEWEDBY-------------------------------- ---- --- -------------------------------------------------------- ------------------------ DATE- ..--_--------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------------- --- DATE----`Z`��-.----------------------------------------------- Alterations and/or recommendations------- -------------------------------- ---------------------------------------------------------------------------------------------- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- •------------------- ---- ---------- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------I----- yC FINAL INSPECTION BY: Date----LZ_y —4-7 ` ---3-------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California + x f, ES-9=2M 10-52 Revised W-2100