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- APPLICATION FOR SANITATION PERMIT Permit No. _4A_____________ (Complete in Duplicate) Date IssuedI--- Applica{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 County Ordinance No. 549. v h # JOB ADDRESS AND LOCATION--- --D------- - ¢ Owner's Name----------77-� = Phone ' p Address �� d.... -------------••---------------•---•-------------;--•------=-------•-----------------•----------------------------- --------- y Phone� Contractor's Name----------- --------- - ------------------------------•--------•------ ------- ---------- Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/__ Number of bedroi oms __cZ Number of baths -/--"Lot size ___�1�.__ � --Q----- ------ - -- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑] Sandy Loam ❑ Clay L�am ❑ Clay ❑ Adobe 9_1�ardpan ❑ Previous Application Made: Yes ❑ No 9�New Construction: Yes R-`No ❑ i l TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if publicysewer is available within 200 feet.) Distance from foundation_-- __4_1___t_.Ma} ri ------ '�• Septic Tank: Distance from nearest well �''� „ r No. of compartments------�-------------Size_-,? ----/�_. �-•---Liquid depth:_---L�...... ---Capacity----- �- ----. �.d� -Di from foundation to nearest lot line Disposal Field: Distance from nearest well--? Number of lines___.___._ .----------Length of each line- s3�1 - __--------------I--Width of trench..-�y---------------------- --.-_ Type of filter material__Sf_'Vk?A3 __Depth of filter material__._J_ ____________Total length-------3d.___-----------___.-___----- 0 Seepage Pit: Distance to nearest well_.27�k -- Distance from foundation---y�_-____.Distance to nearest lot line----------------- d' Number of pits------ -----------Lining material-s! �C�Size: Diameter_:_..33--�--_-----Depth---_�f_--- Cesspool: Distance from nearest well-----------------Distance from foundation------------._,_.._.Lining material-------------------------------------- rn ❑ Size: Diameter----- ------------ -------------------D'e th--= _ ...,, _t--------------- 1.Liquid Capacity----------------------------gals. _....- 1 - -10 Priv Distance from nearest well.__-.-�` ---- --------------------------Distance from nearest building----------------------------------------- Distance ❑ Distance to nearest lot line,--,,L--------------------- ------ ----------------- ------------------------------------------------ Remodeling ------------•----------•---------------------Remodeling and/or repairing (describe):--------------------------------- ----------------------------------------------------------------- -------• S --------------------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------•-------••---•-------------------- ------------------------------- i - r ---- 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 regulations of the San Joaquin Local Health District. ' a� -� . -------------•------------------------- ---------------(O ner and/or Contractor) (Signed}_-----`, Q _ _ "' _/G By:-------------- ----��.�f--------- --`----------- ------------------------------------------(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 APPLICATIONACCEPTED BY-------------__--------------- -------- ------------------------------------------- DATE--------------- ------------------ IREVIEWED BY------------------------------------------------------------------------------------•------ --------------------------------- DATE------------------------------------------------------------ i BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------- ---------- -------------------------- ----- Alterations and/or recommendations:-------------------- ---•-------•-- ------------------------------------.---..------------------------------------------------------ --------------------------------------------------------•--- ----------------------------------------------•------------------- ---------- -----•------- -----------•-------- --------------- -------------------------------•--- ]/ FINAL INSPECTION $Y--------------- ------------- Date---..Date---=----- --------------------• - SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 forth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100