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f APPLICAT}ON FOR SANITATION PERMIT Permit No.�a�.- .- 4l�7 (Complete in Duplicate) �D / Date Issued ____X._� �Ap a�ication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION.... p-Y- -- 4... ----------------------------------------------------------------------------------- ------------- Owner's Name------ - - . ------------------------ Phone__%�/Ju------------ -- ------• - = - --- - - - - - --------------- -_ _ 6 --------------------------- - --- Phone___�TD�' Contractor's Name___ f _ Installation will serve: Residence o Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i I Number of living units: _/-__ Number of bedrooms __Number of baths -__-____ Lot size ---�5-- ��'' ---------------------------------------- Water Supply: Public system D( Community system ❑ Private ❑ Depth to Water Table �4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑ Previous Application Made: Yes ❑ No It4 New Construction: Yes ❑ No�]C TYPE OF INSTALLATION AND SPECIFICATIONS: (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 well.................Distance from foundation________-___._____.Distance to nearest lot line_______._-___.__.� Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- Type of filter material------------------------- of filter material-----------------------Total length___.____.._--------------_- ------ - � of Seepage Pit: Distance to nearest well.N4bioaI------Distance from foundation----�t�__�___------��ante to nearest loot line_ _______.__ --- 1 Number of pits----- -------- -----Lining material_---_-�______-_4__.Size: Diameter._..-_______._.__------Deptn----- -- -_- ---------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material______-__-_______---------_-._-__-_ ❑ Size: Diameter------------------------------- ----- Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line--------------------------/J------------ ------------------------- ---•---------------------------------------------------------------------- iaC.r ------ ----- ------ '' •• -- - j---�-�-••--1------ Remodeling and/or repairing (describe}------ ------- - -------------------- - ----�-----------..-....- ---------- ------- ••--•-----••---------------------------------------------- - rr � -----------------------------------------•-•------------------ -------------------------------------------------------------------------------------- ------------------------------ -------------------------------------•--------------------------------------------- ------------------------------------------------.--------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and rules and regulations of the San Joaquin Local Health District. - i� (Signed) ------ ..... - - --( ner and/or Contractor) ---- - - - - - - --- --- ----- - --- 8Y� ---------------------------------------------- (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). /FOR-DEPARTMENT USE ONLY 'l ----------------- --------------- *� ------------------- APPLICATION ACCEPTED BY--------------------------�----- ------------------------ DATE-- -- -,� REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE----------------- ------------------------------------------ BUILDINGPERMIT ISSUED-----------------------------------------------------------•----------------------------------------- DATE--------- --------------------------------------------------- Alterationsand/or recommendations---------------------------------------------- -------------------------•--•----------------------------------------•---•--------------------------------------- --------------------------------------------------------•------- -•---------------------------------------------•---•--------------------------------..-------------------------------------------------------------- ----------- --------------------------------------•---------------------------------------------------------------------------------------- -•-------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------ -------•-------------------------- ------------------- --------------------------------------------------------------------------------------------- � --;� / -�� -- FINAL INSPECTION BY- --------------- - Date----------------=--------- -----f--------------------------------------------- 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 a ES-9-2M 10-52 Revised W-2100