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5 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ��}7_ J/ u � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Oescribed. This application is made in compliance with County Ordinance No. 549. '.— ((QO 2-375--W. S ��" � � JOB ADDRESS AND LOCATION .«--------3--�� f�� " �,/ Owner's Name / X ------------ Phon `y_ _ c Address__ -------------------------------- ----------------------:-------------•----- ------ -• ------�- 3,0p Contractor's Name-- ------------------------------------------------------------------ ---------------------------------------------- Phone----------------------------------- Installation will serve: Residence,4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I_ Number of bedrooms . -__ Number of baths _017--- Lot size ___"S_ --------------------------------- Water Supply: Public system E] Community system ❑ Private 20 Depth to Water Table — ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No N New Construction: Yes .X No ❑ -fit/VA: 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 nearestwell y":_'Distance from-fouridet;on--./P---------Materiai- ----------------------- No- of compartments_.__.2.------------------Size--------------------------------Liquid depth-----_--------------------Capacity-_ 4114n--- _-- Disposal Field: Distance from nearest well.,-D-u------Distance from foundation- 4-------------Distance to nearest lot line ... �1 .1 Number of lines-------2--_ _____ engfh of each line----1�-'_-__-__-__--.Width of trench.__�V_"0-------------------- G] Type of filter material Depth of filter material_Zar-a-------- Total length___;-_0V---------------------------- Seepage 'Seepage P;t: Distance to nearest well-.- -_-_-__-_+'_:Distance from foundation-------------------.Distance to nearest lot line--_-..--___---.- ❑ dumber of pits----------------------Lining material----------------------.Size: Diameter------------------------Depth----------------- ------ Cesspool: Distance from nearest well-----------------Distance from oundation-----.-.-.-._---.--.Lining material-.__-._-____---_----_--..--_.____--. ❑ Size: Diameter------------------------- -----;Depth--------- )----- I---------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearestwell---'_-:-..__---.--------.-_I-------- ______ __Distance from nearest building.--.------.-_-_----.-----_____-----__-. ElDistance to nearest lot line----------------------------_______ ------= �' Remodeling and/or repairing (describe):--------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- -- I I -- -- _ - - --- - - - - - - -_ ---- - -- ----------------------------------------------------------- 1 hereby certify that I have prepared this application and that the work will beAone in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed} _ - --------------------------------------------------------------------------(Owner and/or Contractor) Plot plan. showing size of lot,;-location of system in relation 1 Title By:------------ -- •- -- - ------_---- ----- -------- -- ---- -- -- --------- -----{ )---------------------------------------------------------------- ( p g y to'wells, bwldrngs,�etc.,Tcan be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _ ------------------------------------------------------------- DATE----"a^ __'-r --------------- REVIEWEDBY------------------------------------------------------------------------- ------- ------------------------------------ ------ DATE----- ----------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------- -------- -----------------------------------------------------------------•-••--------------------•--------------------------------------- ------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------- p --------------- Date- —=�- ` % ----------------------------------------- : FINAL INSPECTION BY_ ___ _ _ __ __ ---.----.- --- 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 i ES-9-2M , Revises 1.57 EP.CO.