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, APPLICATION FOR SANITATION PERMIT Permit No. ..4-7` ------ J (Complete in Duplicate) ` Date Issued __ ___ ---- Applica{ion is here y made to the San Joaquin Local Health District for a permit to construct and install the work herein describ d. This application is made in compliance with County Ordinance 549, JOB ADDRESS AND . CATION___.__ _�- - �_ Owner's Name a '?'R'4- -- Phone------ Address----------------- -42- fes ------------• - ---------------------------------------------------------------------------•-----------------..._...... Contractor's Name------------- + ------------------------•----------------------..---- Phone---J?--`--- fv----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/... Number of bedrooms __z;2—Number of baths __/___ Lot size Water Supply: Public system t[--Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[R-"Hardpan ❑ Previous Application Made: Yes ❑ No EKY New Construct'on: Yes ❑ 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---------._____Distance from foundation______________ __.Material____-________-_______.__.._________..__________- ❑ 0,vC+�,. No. of compartments--------------------------Size------------`--------------------Liquid depth------------------------ Capacity-•-------- ------------ Disposal Field: Distance from nearest welf___.............Distance from foundation._---_-____________.Distance to nearest lot line.--.___..___...._ ❑f�fi Number of lines------- _.---------------------Length of each line------------------------------Width of trench-----------------------------__---- ` �� ` Type of filter material_________________________Depth of filter material___.____.----.--_-,___Totallength_____________________________________ _ J�J Seeps Pit: Distance to nearest w/ell____.__ __.__Distance fro oun ation___��_______-Distapnfe to nearest lot lin ___ 0_-__ Number of pits_________ l - Lining material��_ 5ize: Diameter--- 3-----------Depth--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------.___-_-----.___.____________. ❑ Size: Diameter--------------- -----------Depth--------------------•------------------------ --- Liquid Capacity---------------------------gals. Privy: Distance from nearest well_____________________________________.._____..._Distance from nearesr building_____-_______________-_-._-__.__________. ❑ Distance to nearest lot line-------------------------------------------------------------------------- ----------------------------------------------------------------- 77r� � - ------# Remodeling and/or repairing (describe):--- 00-I&--- W- ' ------ -----------------------•--•------ ---------------------- ••----------------------------------------------------------- ---------C----------------------------------------------------------------------------------------------------.......-----------------------------------------------------------------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ]aw and rules and regulations of the San Joaquin Local Health District. Q-t�'-. --------------- ------------ --------- ------------------------------------------------------ -------- r and/or Contractor] (Signed) - 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---------._._.. . REVIEWED BY--------------------------------------------------- � � -- r - ----------�-------------------•--------------�--- • --------------------------------._. DATE_--•-----• •- ------....----• -•-------•----------------- BUILDINGPERMIT ISSUED.......------••---------------------- ----------------•--------- ----------------------------- DATE..--------------------- ------------------------------------ Alterationsand/or recommendations--------------- ------------------------------------------------•--•--•-------------------------•---------•-•---------•-- -------------------------------- ---------------•-------------------•------------------•--•---•-----------------------------------------------------------••-----•-------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------•------------------._...--•-------------------------------------------•--------------------------------------------------- •--•-•---------------- •---•-----•------------•----------------------------------------•----- --•------------•----- --------------------------•------------------------••---•---------•---•----- --------------------------•-- - -- --------------------- ---------------------------------------------------------------- •----•-------------------------------------------------------------- S FINAL INSPECTION BY: Date-------------- -----�--1------------------------------------ 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 ; Revised W-2100