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•. Z" ;,� APPLICATION FOR SANITATION PERMIT Permit No. ..... (Complete in Duplicate) Date Issues! - -- :o?1:Fr" ._3 Applica+ion' is hereby made to a San Joaquin Local Healt District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinofe No. 549. ---- JOB ADDRESS AND LOCATION.._"_ _ o!� , < - Owner's Name • -- -•----- n .--------.•-____-- ----------------------- -------- Phone Address -------------•-------- •----------------""--- ..- -------•-------------•---------•--------------- ----- -•--•----•------ -- --- - --- --- - ----------Contractor's Name-----• ---------- Phone.----- -r� Q7.Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ Number of living units: fNumber of bedrooms _1-_'_'Number of baths __� -- Lot size c��, ----------- Water Supply: Public system ❑ Communitysystem Y ❑ Private 'Depth to Water Table 3,0 ft. Character of soil to a depth of 3 feet: Sand [-I Gravel ❑, .Sandy Loam ❑ Clay Loam E] Cla Previous Application Made: Yes Y [I Adobe E] Hardpan [] ❑ No,�- New Construction; Yes ❑ No �� ,/ �,• { TYPE OF INSTALLATION AND SPECIFICATIONS: } , �G/� e��•.. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Distance from nearest well-----------------Distance from foundation------------------:".Material r t__ �J No. of compartments---------------- r Size Liquid depth --------------------------Capacity----------------------- w P ie Distance from nearest well_ - --- Distance from foundation-��.__'?�7.Distance to nearest lot line.---- Number of lines----- ----------------------------Lengfh of each line------ �~,O t, n ,r -------.Width of trench- ----- -------------- Type of filter material-�y_-_A?—A, Depth of filter material___�_S-!__ - _-Total length_".""�G------------------ Seepage Pit: Distance to nearest well-.--------------------Distance from foundation_.-----._-_..----_.Distance to nearest lot line-_--_._----__-._. ❑ Number of Pits----------------------Lining material-_ __"_________--Size: Diameter___-__-__---"" Cesspool: Distance from nearest well----------------- --- Distance from foundation_.___-"-___---- Lining material------------------------------------- Y --"--- ""-__-"- "" " ------ ize: Diameter------ �------- -------- --------Depth- - -------- ----------- -------- --------- ----Liquid Capacity-----------•---------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line"""___"___-"_"_______ Remodeling and/or repairing (describe):---_-* ` I .""_____ 0 ------------------- ------•------------------"-----•----------- _ __________•-_-----_-__--_----.----_--.____.""""--___"---_-__---_-_------__-•-"-__--•-_•--_---•---------------------------- ' I hereby cel' �" y that I ve prepared this l�appli afion and A i the work will be done in accordance with San Joaquin County ordinances, States,laws, and ru es and r gulatio� of +he San Joa in Local Health District. (Signed).,-------------- -- -•-•- - - - By:--------------------------•-----•----•----•------- Title � ontract or --------------------- (Plot plan, showing size of lot, location of system in relafio f wells, buildin "" ate., can be pI sed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--"_. i �p REVIEWED BY y DATE------- -------------------------------------- - - ---------------------- ------------------------------ - DATE_ --------- - - --------------------------------- - BUILDING PERMIT ISSUED-------------------------- -- ----------- DATE". Alterations and/or recommendations: � - -----.............................. ------------------------------------------------------------ -- -------•----------------------------------- - - - ---------------------------- ------------------------ FINAL INSPECTION BY-- -- ----------- ---------- - I" ! ------------ Date---d. " SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes} Oak S}rest 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M ' Revised W-2100