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AP �- PLICATION FOR SANITATION PERMIT Permit No (Complete in Duplicate) / Date Issued --- � -`I-S j 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. JOB ADDRESS AND LOCATION----------------- __!--4 _ -D - Owner's Name_________________ ------------ ---------- ------------------- ----_------------- -------- Phonej- Address ---------- ------------- ------------- -- ----- ------------------------------------------------------------------•- --- ------------------------------------------ Contractor's Name-------•-----------:---------"""- -d�w--------------------------------------------------------------- -------------- -•-----...--- Phone----••--------------- -----------Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms __- Number of baths __I____ Lot size Water Supply: Public system ❑ Community system ❑ PrivateX 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 ❑ No A New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIF)CATIONS: (No septic tank or cesspool permitted if public sewers available within 200feet.) No. of compartments_______'"O ndation_'--- _��______. Septic Tank: Distance from nearest well__.'_ -� D eance from fou_3�� Liquid depth k depth ��"`�_""i Capacity-. _________- ---- __C?.-"""Disl Field: Distance from nearest well----5 ._Distance from foundation______- Distance to nearest lot line- S4 of lines----._.___�_________________-_--Length of each line_____ _ Width of trenchz^c, �1 Type of filter material.�-- De th of filter material--------._tr-Q.______.Totdl len th_____________ 45-0""-"- (y-- " ---- Seepage Pit: Distance to nearest well __Distance frornJoundation___________________.Distance to nearest lot line_--__.__,_.___--_ ❑ Number of pits----------------------Lining material__- ------------------Size: Diameter---------- ------------Depth----------- -------------- Cesspool: Distance from nearest well_________________Disiance:from!foundation------___________- Lining material---____._____--_________._. ize: Diameter-------------------------- ----------- --------------------------- ------------------------Liquid Capacity--..- gals. �.� Privy: Distance from nearest well------------------- _______ __________Distance/mr, rest buildin j � { g - ❑ Distance to nearest lot line---------------------- - Remodeling and/or repairing (describe)_______________ _�---__" "/___I--%-__-__" , ------------------------------------------ -------------------------------------------••- --•----------------- ------------------------------------------------------------ f - ------------•----------------- y prepared this application ,and -------------------------------------------------------------- ------------ ------------------------------------- _' ----------------------------------- --- herebycertify that I have and th t the work will be done inaccordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) I „, ---------------------------•------------- Owner ( and/or Contractor) By:---•--------------•---------------•-------------- ---- - ------------- t------ --------------------------------------(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-----------•-- - - - -- -•----------- r 1 WED BY--------------------------------------------- • --------------- ----------- � �•� � ,j................. DATE ----------•---------------------- UILDWG PERMIT ISSUED DATE Alterations and/or recommendations:_______ _ ----_ ----- "_ -- "------------- --” —5-- - _ _ -?fie------, ----------=n .P.---- ~. ---- -------------------------------------- �------- -----------------•----- ----------------------------------------------------------------------------•----------•-------------- ------- -----•----------------------- ------D.------ -- FINAL INSPECTION BY:------- lJ " r! Zt ""--rn/iZ ---------- ate. 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 10-52 Revised W-2100