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APPLICATION FOR SANITATION PERMIT Permit e, A;q r 7(Complete in Duplicate) Date Issued __ --z- herein _/_ ` g1�� pplication 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. JOBADDRESS AND L CATION_�- --- �- ---- ---- - - ----------------------------------------------------------------------- = Owner's Name - -- -a- Phone Address---------------------------------- - �.. --------/�--- --------------- --- - ---- ---------- ---- ---- -- Contractor's Name �7 *- -- -`-�G-C�---------------- -Phon Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑/Motel ❑ /Other ❑ Number of living units: ___-- Number of bedrooms -W- Number of baths J--- Lot size __!____` 4 ! �'� Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table_,>--V_ ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam E] Clay Loam El Clay [-1Adobelardpan ❑ Previous Application Made: Yes ❑ No EA Construction: Yes ❑ :. 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!Q-------Distance from foundation--/.d_---____.Mat ri L '_ _ ------------ -------------- t• t No. of compartments----- r-------------Size----- - 1tr-Liquid depth----� �--------Capacity__ --------- Disposal --__ -- Dis osal Field: Distance from nearest wel 1 ��___-__--_Distance to nearest lof line__ ______y P I_� _____._.Dis ante from faundatio _ Number of lines__I__,_,_�__,_ ---Length of each line_______'___________ Width of trench__ ______________________�___ Type of filter material _ K�Lt----Depth of filter material____1_�-*--.____Total length__,1.2_ .-- Seepage Pit: Distance to nearest well__ ___________________Distance from foundation______.._-_________.Distance to nearest lot line_______________- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--_____----------------Dept h--------------------------------- p --------------------Lining material-------------------------------------- Size: —' Distance from nearest well-------------- -Dis -- from fo'usndationLiquid Capacity-----------------------------gals. Size: Diameter--------------------------------------Depth-------------- -- - --- --------- Privy: Distance from nearest well------------------------------------------ ___Distance from nearestbuilding__ I] Distance to nearest lot kne---------------------------------------------- ------ ----- - ----------------------------------------------------- ------------------- -- i Remodeling and/or repairing (describe):____________- �l•+�If_c - ------------------------------------------------------------------------- 1 ------------------------------------------- -----------••------------------------------------------------------------------=---------------------------------------------------------------•------------•-------------------- -- --------------------- ---------------------- = ----------------•---------------------------------------------------------------•----------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r gulations f the San Joaquin Local Health District. {Signed) d { 6 C _ '- --- ----------------------------�---- { �eraar Contractor) r B -------------- •� !----1�--- - --------- - [Title)-----2 - ----------------------------------------------- Y� [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 k � APPLICATIONACCEPTED BY-------------- --- -- -----------------•-------------------------------------------- DATE----------r ---------------- REVIEWED`BY---------------------------- --- ----- ----------------------------------------------------------- DATE------------------------------------------------- --------- BUILDING PERMIT:ISSUED----------------------------------------------------=----------------------------------------------- DATE---------------------------------------------------------- - Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------------- •------------•-------------- ------------------------------ FINAL INSPECTION BY------------- - )----------------- Date--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 4 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 4 ES-9-2M 8-51 Revised W-2100