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APPLICATION FOR SANITATION PERMIT Permit No. .......`?__----_ (Complete in Duplicate) % Date Issued .__-f_� S-0 ___ �_____L-_____ 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. 549JU-11 JOB ADDRESS AND LOCATION-------f =_ -------- -----•------------------------------------------------------- Owner's Name. --- ------------ ----------------- -----,.----------- : Phone F Address + -._ 1.� - - -------------------------------------------------------------------••---- Contractor's Name ,z` `e_-- Phone-Ae__-�- �9 Installation will serve: . Residence /Apar+meet House ❑ Commercial ❑ ' Trailer Court E] Motel ❑. Other ❑ Number of living units: '------ Number of bedrooms _Number of baths Lot size .------'7__ _ __ ..( ________________________ Water Supply: Public system tSt_Community"system ❑ Private ❑ Depth to Water Table _46ft. Character of soil to a depth of 3 feef:� Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Rk. Hardpan ❑ Previous Application Made: Yes 0 No 5L- New Construction: Yes Z No ❑ O TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �1,�}} SepticTank:` Distance from nearest well------------------Distance from foundation___________________.Material_._____-__-__________.__-......__-_________._. [� &o. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity__--------------------- Dis.posal Field: Distance-from nearest well---____-----------Distance from foundation--------------------Distance to nearest lot line-------.......... ❑ Number of lines-----------------------------------Length of each line-------•----------------------Width of trench------------_.------.....---.....-- Type of filter material-------------------------Depth of filter material----.-------- .-------Total length________-_____________________________-- Seepage Pit: Distance fo nearest well_-_W_6-�istance foundation----o'ZEe-------Distance to nearest lot line___ Number of pits-------- -----------Lining rnaterial ;_ dz Diameter-------5 -Depth.......1 ---------- Cesspool: Distance:from nearest well-------------------Distance from foundation....................Lining material------------------------------------ Size: Diameter------ -------------------- ----------Depth-.--------------------------- -------------------Liquid Capaei+y----------------------------gals. Privy: Distance from nearest well-_-_=__--.____----------____________ Distance from nearest building____________..__________..__-.__-_____ . ❑ Distance to nearest lot line_--"�'__--_--- i _______________________________________________________________________________________________________________________ Remodeling and/or repairing (describe):------------,------------------------ -------------------------•---------------•-•---------------• ---------------•--•----•------•------------------------ --------------------- ----•__•----------------------_----------------------------------------------------------------- -----•-•--------------- ---------•--•-•-------------------------------------------- I hereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State , and rules and regulations of the San Joaquin Local Health District. + (Signed) �% - -—-------------------------------- - O ner and/or Contractor i 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------�----------------------------------------------- REVIEWEDBY-----------------------=------- -- ----- ------- --- ----------- ------------------------------------------- DATE----------- BUILDING PERMIT ISSUED---------------------------------- J Alterations and/or recommendations_________________________ ---_ -- --------------------------------------------------- - ------------------------------------ -0- 4wi ------ '_ -- ---: ------------------------ = ------------------------ -------------------------- ----•------------------------------ -------------•-•----------__--_-------------------------------- ... - --- -- ------•------------------------------------ ----------------- ----------- ---------- --- ----------------------- ---------------------------------------------•-------- •------------------------- ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ i FINAL INSPECTION -BY:--------- — -----_ -Date----._._. _-"-- --is------_ 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 145446 ATW,19" 12.54 G