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op APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ! O Date Issued ___._ s3r-3/.5�j Application is hereby made to the San Joaquin Local Health District for a per 'it to construct a install the wo herein described. This application is made in complia ce wit aunty Ordinance No. 549. JOB ADDRESS AID-kQGATIO ------- -- -- - - ---------- --------- - ' J� Owner's Name --- - .....{ -'------------------------------------------- Phone__Ae=. . -- Address e,__y ---I- ----------------- - .. ._ Contractors Name ----------•- - �---- --- --- Phone-6.- - Installation will serve: Residence �Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/--_ Number of bedrooms -17:::-Number of baths ___J__ Lot size ___ �2 '- __... __J�'- ,_ Water Supply: Public systemCommunity system E] Private E] Depth to Water Table .------- ft. Character of soil to a depth o 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla m ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Noa New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: . Distance from nearest well-----------------Distance from foundation------------------- Material------------------------------- ❑ No. of compartments Size---------- --------- -- ---------Liquid depth---------------- --....._Capacity------- ------------ Disposal Field: Distance from nearest .,lt ' _.Distance from foundation---I_±D--- --_-Distance to nearest lot line____ _ W1 Number of lines------- Length of each line--_-_�D._s�_j�-_____ Width of french_____.___.___-__---_.___.________. Type of filter material---lJlr.�,��_._Depth of filter mate rial____. � O----f---Total length_. _-____________________�:i Seepage Pit: Distance fo nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line------.---------- s ❑ Number of pits----------------------Lining material----------------:------Size: Diameter----------------------.Depth.......__.----------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Uning material_._____--_----_-___.-___ ❑ Si7e: Diameter--------------------- --------------- Depth-----------------'-•--------------------------------Liquid Capacity-----------------r---------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------------------------------------- Distance --------------------- -----------------.Distance to nearest lot line------ -------------------------- ------------------------------•------------ ----------------------- Remod in and/or repairing (describe}:--- ----- ---- ---• ---------------- ----- + &----------------- •-----•- -.....A - �•--`-•----------------- - --------------------------------------- -------------- ---------------------------------- •---------------------------- �[—I ----------(_x--------•-----------------�- ....--•}- -- -------•-•-----•-°---------------------------------------------------------- ----------------------------------------------------------------------•------------------------------------------------------------------------------•------• --------------------------------------•- -------------- �, I hereby crtify-that-hhave prepared thiss,,application and that the work will be done in accordance with San Joaquin County ordinances, Stale laws, and rue and re ulatio`hs of the San J.d�qquin Local Health District. (Signed}-------- ------------- ----------------------------------- ontractor By: ----------------- - --------------- (Plot plan, showing size of lot, location of system in relation a wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- ------ 1 ! - " ";..... ---------- DATE--- REVIEWEDBY - -------------------------- ------------I------------ DATE--------------- BUILDING PERMIT ISSUED-------------•-----------------------------------------------•---------------------- ----------- DATE--------------_-- Alterations and/or recommendations---------------------------------- -----------------------------------••------------------------ ----------------------- --------------------------------•-------------- ------------------- --------------------------- ------------------------•---------------------------------------------------------------•----------- ---------•-----------------------•-------------------------------------------------------------------------------------------------- ----------------------------•---------------•--------------------------------------- --- ----------------------------------- ------ -- ----------------- f FINAL INSPECTION BY:..--------- i ---- - Date-------- ------- 17_�,A t -- --'-- --------------------------- -- 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