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.A?4_4 .YY//APPLICATION POR SANITATION PERMIT Permit No. _._v (Complete in Duplicate) Data Issued _ 1 I / Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ' This a�plicafion is made in compliance with County Ordirlprice No. 549. JOB ADDRESS AN.D,LOCATION-- ---- ------------- ---7-5 --------------------------------------------- ------------------ Owner's Name_ Phon d �/� �` --------------------- Address --- - -. Contractor's Name----- ----------------------------------------------------------- Phone__io_,-,-Z Installation will serve: Residence;g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ I Number of living units: _ __ Number of bedrooms . ._ Number of baths __/__ Lot size -------S�_X_1SSD___________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 1! ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' 'Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 41, . ank: Distance from nearest well________________Distance from foundation_______---_--_____.Material______._______._______-___-.. : �No. of compartments-------------� N1�--``------ ----Size--------------------------------Liquid depth----------- --------Capacity--------------------- Disposal Field: Distance from nearest well/i 6Distance from foundation___ 0___----Distance to nearest lot line___a�__�_� Number of lines._ r Length of each line___:___ _S �" ___Width of trench---------- \ Type of filter mateDepth of filter material____._IS!______Total length------0_11 __ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------- ---------Depth____...____----_---____--------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- F1 1 Size: Diameter--------------------------------------De th------------------- ---------------- --------------Liquid Capacity--------------------------•gals . Privy: Distance from nearest well----------------------------------------------._Distance from nearesr building-------------------------------- ----_._. ❑ Distance to nearest lot line---------------------- ------------------------------------------•-•----------------------------------------------------------- I I, Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------- ---------------------------------•------------------•-- II -•-----------------------------------••----------------•-•-••----•--------------••------------------------------------••--------------------------------------------•-------•---------------•------------------- ----------------------•--------------------...--------------------.---•-----------------------------------------------------------------------•----------------------•---------------------------------------- I) I hereby certify that I have prepared t - his 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. 4 (Signed)-------------------------- -- ------------ ----------------------- ---- - -------------------------------------------------- $y: - - - - - - -------- -(Ow rand/or Contractor). ------ ----- -- ----------- ------- - ---------- -- - -------- 1 (Title)_ (Plot plan, showing size of lot, location of syste 1n relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLI6ATION ACCEPTED BY----------- -----------------------------------------*--------------------- DATE-------- �. REVIEWEDBY--------------------------------__--- ------------------------------------------------ ------ -- ------------------------- DATE------------------------------------------••------------ BUILDING PERMIT ISSUED ------------------------ DATE Alteratiions and/or recommendations---------------------------------------------------•----------------------------------- ---------------------------•-•-•----------------------------------- I ,, ---------- ---------•-----•---------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------- - II - --------------------------- ------------------------------------------- --- --- ---------------•----------------- --------------------------------------------------------------------------- ------------- ij I q 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 x ES-9L2M I0-52 Revised W-2100