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'APPLICATION FOR SANITATION PERMIT Permit'No. _. ------------- (Complete __(Complete in Duplicate) i Date Issued _ (1_/s__S_______- Applical-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 Countydinance No. 649 lk�JOB ADDRESS AIN,D L CATs -------------- --------- -- ------- y�s�f Owner's Name f f_ __ =-------- �------------=--------------------------------- --------- Phone�P-0-----`-_� -d _. Address------ --• .J---- -----`- ------- --------------~----------------------------------- ---•----------------------------------------------------------- Contractor's Name----- ---•-------------------- ---------------------------------•---------------------------------------------- ---------------------------- Phone---------- •- -------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 11j Number of living units: __d-___ Number of bedrooms _074 Number of baths --L- Lot size - � 1--- - -------- ------=- 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 Q' Clay Loam ❑ Clay ❑ Adobe 0""/Hardpon ❑ Previous Application Made: Yes ❑ No ®� New Construction: Yes �N0 ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material_._______.______--_----.---____________._---____. No, of compartments_--_-- -- _-_ ---.Size--------- ---------------------Liquid depth--.-----------------------Capacity---------_------ r Disposal Fie Distance from nearest well ._ __ Distance from foundatio t_______ Distance to nearest tat lin .. ` Type ! Depth of fil , rr Number of lines__�___-_-_ ! - Length of each line___________ __ _ ____..Width of trench__ _J> __ _"_______ ------- T e of filter mater l_ _„ � ter material_-.__-_R__16 -----Total length__________ ___________________________ Seepage Pit: Distance to nearest well___='_____-:------Distance from foundation____________________Distance to nearest lot line______________. ❑ Number of pits---- .-----------Lining.material-----------------------Size: Diameter-----------------------Depth-.--------------------.---------- r � •i i'T' Cesspool: Distance from nearest well_________________Distance from. foundation---.--------------- Lining material_________________________________ ❑ Size: Diameter--------------------------------------DeP �. -- ------ Liquid Capacity gals. , Privy: Distance from nearest well-___________________'-__-----____.______I-----Distance from nearest building______.___________________________------ ❑ M Distance to nearest lot line-- ;-------------------------- ------------------------------------- --------------------------------------------------------- 'N, Remodelingand/or repairing Idescrikie)-------------------------------•------------------------------..-------------------------------------------------------------------------------------------- -------------------------------------------------------------- --------------•------------- -----------------I......------------ ...------ tt, -------------------------------------------------------------------------------- •------•-- ---•--•--------------------------------- --- - -- --- - g -- ------•-------------------•-------------------------- --------------------------------------------- I hereby certify that I have prepared this application and that the!work will be done in accordance with San Joaquin County ordinances, State lawsf and rules and re ulatio�nlssiof the San Joaquin �cal Health District. `r .__Owner and/or Contractor (Signed)-----� ='P�r"�---f="---- [ / I 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- DATE ---------------------------------------------------- REVIEWED BY ------------------ ----------------- DATE BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------- -------------- DATE------- ----------------------•--•-------------... -- Alterationsand/or recommendations:i----------------------------------------- ---------------------------------•---------- I---:_.------------------------------------------------------------- ---------- --------------------•---•----------------•--------- - .,. a 4 -------------------------------------------------- -------------------------------• ---•--------•------------•------f--•---•-------- -•--'•---------------------•---------------------------------- -- -- „ --------------------------------- ---------------------------------------- . FINAL INSPECTION BY------------- ------ --------- Date.----------f SAN JnAA0QUlN 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 -