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' APPLICATION FOR SANITATION PERMIT Permit No. ,�_l..-.l e� (Complete in Duplicate) Date issued/___3tet~ _'..__- 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 County Ordinance No. 549. 99 JOB ADDRESS AND LOCATION_____"`YL.____-t,_________._.l�-______��___d1'1 e s, � f Owner's Name-------------- -- --A.------- __�1�je'i / --- ---- Phone---------------------- Address- t 1 t T----------------------------------------------------------------------------------------------------------- Contractor's Name --------------------------------------------------------------------------- �-------------------------------------------------------- Phone ______________.______.__._ Installation will serve: Residence [E' Apartment House [:]Commercial ❑ Trailer Court [:]Motel F1 Other ❑ i .4i __ - Number of living units: __l ___ mbar of bedrooms 2 Number of baths ____ Lot size .-__--1�_._- r. Water Supply: Public system V Community system ❑ Private ❑ Depth to Water Table'"t. v Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No (Q New Construction: Yes 9 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_'A'_�.___..... Distance from `f9u ciWion_ _ w^ti_.Ma fial__-- --A• ---------_--. ® No. of compartments --- .2__- gT_._. ---- --- ----Size-. ---- - - �� _ Liqu d depth Capacity OGI i Disposal Field: Distance from nearest well d ___._Distance from foundation�b "7_"'^_.Distance to nearest lot ------- Number of lines ----------- Length of each line___ C-iQ___----- Width of trench_._ ___ Type of ri filter mateal_._-5,_/�IG - Depth of filter material_ __l/ '-________ Total length ------ - �____________________ TT ----- Seepage Pit: Distance to nearest well _____------- _--- ____Distance from foundation -------------------- f]isfance to nearest lot line __._______.____._ ❑ Number of pits---------------------- Lining material --------•-------------- Size: Diameter----------------------- Dept h --------------------------------- 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 County ordinances, State I ws, andrules,�and regulations of the San Joaquin Local Health District. (Signed) --------------- -�-•• -- •---�- --- ---- --------------- (Owner and/or Contractor) By:---------------------------------------•-•------------------•--------------------------------------------------------------------(Title)-----.---------- -------------------------- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). f} _ -, A, -"FC* DEPARTMENT USE ONLY =-�.: - 1APfLICATION ACCEPTED DATE=:__W_--------- V REVIEWEDBY--------------------------------------------------------------------------------------------------------- DATE ----------------------------------------------------------- BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------------------ DATE --------------••----- ------------- -------------------------- Alterations and/or recommendations: ---------------------------------------------------------------------------------------------------------------------------------------------------- _..------ = - ---------------------------------------•--..._.... ------ --- --- ------ ---------- ♦ 6Gi % yt --•c9 P ----- ;q; _ -`� --- ------------------- J .--------- V FINAL INSPECTION BY:_________ _______ . -------------------------- Date d. ---------------------------------------- V 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 Revised W-2100- "- +� R•