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/,s APPLICATION FOR SANITATION PERMIT Permit No.(Complete in Duplicate) Date Issuedcation is h 11e made to the San Joaquin Local Health District for a permit to construct and install the work herein described. pplication is�n de in compliance with County Ordinance No. 549, i y - j JOB ADDRESS AND LOCATIONd `� - --------------------- / Owner's Name. r ----------------------------- ------ --------- --------------- Phone--4 -,---C-- k Address-.-- ¢_ l Contractor's Name-,------ IrD/ -- --•--------------------- _------ Phone__- ,�'D_6 2 � Installation will serve: Residence Apartment House Commercial ❑ p ❑� ❑ Trailer Cour} ❑ Motel ❑ Other ❑ Number of living units: o -=_ Number of bedrooms ___ _-_ Number of baths __ _ Lot size _--__ - _�_ --1-- - -----------_-_----- Water Supply: Public system X Community system'❑ 'Private❑µ DepthW Wates Table 151__A ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑. Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ i —�+ ) Previous Application Made: Yes ❑ No New Construction: YesX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ; p Nis n co r artmareS`r _ _ Distance from fouvndation--_1®_,----...Material_____________________...___--___..____...___._. Septic Tank: Distance fr p nee yes�w�oell�p---: � S1Zes,� X,�b XS/d ,L ,Liquid depth Capac,+Y Disposal Field: Distance from nearest well-,4WWDistance from foundation__-�___-_-.Distance to nearest loft line_._S--__-___--� Number of lines-----------/---------.-.__------Length.of each kne__3 '_Y/U>. _ .Width of trench-----�-` "-----------------` Type of filter material__47-1? -4--_Depth of filter material-__---/1- --- _Total length---____ -_-_------__•_-_ Seepage Pit: Distance-to nearest well N# -Distance from foundation____�rr.I__._-.Distance to nearest lot line_-_`_S.__--_- • ---- . -9--�--------Depth-------`'-----•--- Cs Number of pits.._.__________-_ Lining material Size: Diameter____ ---------- Cesspool: Distance from nearest we}l-_____________---Distance from foundation--------------------Lining material------------------------------.__- --� ❑ Size: Diameter------ 3------------------------------Depth---`-------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------..------_-.______...____-__._.______---_Distance from nearest building------..__--_-___.__--- ------------------- ❑ Distance to nearest lot line---------------- Remodeling and/or repairing (describe):--------- ------------------------------- ---------------------------------•--------- I ---------------------•------------------------------------------------------------------------•------------•------------------------------------------------------------------------ -- E 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. Si ned g )---------•-------------••-----------------------�--�-----�--��-------------- ------------------- ----------------------- - ------------------ -(O ner and/or Contractor) By:--------- .]kJ� ----- --------------------------------------------------------------(Title)_ (Plot plan, showing size of lot, location f system in relation to wells, buildings, etc., can be plaeed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYDATE '� - g---------------- -- ' REVIEWEDBY--------------------------------------------------------- -------------------------------------------------------------------- DATE--- BUILDING ERMIT ISSUED----------------------------- -----------------------------•------------------------------------------ DATE-------------- - Alterations and/or recommendations:-------------- ---------•-------- ---- ---- -------------------------- --------------------------------- ----------------------------------------------------- ------------------------•------------------------------------------------------------------------------------------- --------- -------------•--------------------------------------------------------- ------•-•--------- ------------ ------- ----------------------•--•--------- --------- --------------------- ------ ---------------------------------------- FINAL INSPECTION BY_____________ Date------------ _ - ` ------------- 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