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APPLICATION FOR;SANITATION PERMIT Permit No. ,----?-- (Complete o. o----_L.-_(Complete in Duplicate) € Date Issued ------- ------,L I Irl lication is herebymade to the San Joaquin Local Health District fora permit to construct and install the work herein described. pP q p , t This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------- -•---- l-ktrG f y'------------------------- -------------------------------------------------------- Owner's Name---------------- --------- - Q ► --------------------------------------------------------------- ------------------- Phone--------------------------- -------- Address ` ------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other [] // ♦ yy Number of living units: ___j___ Number of bedrooms ___ - Number of baths _,l___ Lot size ___�fp_ - _ ��_____________________ Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septic Tank- Distance from nearest well-----------------Distance fromfoundation-------------------Material-------------------------------------- ________ ❑ F✓+ . ?61 1 No. of compartments--------------------------Size--------------------------------Liquid depth---------- ------Capacity-------------- ------ Disposal r ' [ Number of lines----------1---------------- ----Length of each line---------6�._--;--------.Width of trench-----�I` ----__-_____--------- Dis osal Field: Distance from nearest well.__.�j_ __ �� _ _-_Distance from foundation__�_�._________Distance to nearest lot line_________________ Type of filter material__S�rl_ _-Depth of filter material-----/9 ...Total length_____--__.!�- _________________________ Seepage Pit: Distance to nearest well---__-----------------Distance from foundation--------------------Distance to nearest lot line___-_-__-________ ❑ Number of pits----------------------Lining material---------------------_-Size: Diameter------------.-----------Dept h-----------------------_--------- W Cesspool: Distance from nearest well-----------------Distance from foundation---.__.____.-----._,.Lining material-------------------------------------- El Size: Dian-I--------------------------------------Depth---------------------------------- -----------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-__________--___--__--_-____-___--___-_-_. ❑ Distance to nearest lot 1ine--------------------------------------------------------------- ------------.- Remodeling and or'repairing (describe):_________ --_____��y �17__D =_ ___ __--_'r^£� ------------ ---5- 4-1-'1------------------------------•---------------------------------------•--------------••--------------------------------------------------------------------------------- • --------------- -------------------------------•-•-------•--•----_..-------------------------------------------------•...- ------------------------------------------------------------------------------------------ II L _____________________________________________________________________________________________________________________________________f___-___-______________________________________________-_--.______________--__-___--_--_ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and ru es and regulations¢of'the San Joaquin Local Health District. jj (Signed)----- Q'__�" -------•-----------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEfARTII USE ONLY APPLICATION ACCEPTED BY------ ----- - - - - - - - --- -------- ATE-------- -- REVIEWED BY--------------------------------------------------------------------------------------------------------------- -- ----- DATE------------------------------------- -------------------------- --------------------- BUILDING PERMIT ISSUED. ------- -------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------------------------•-------------------------- . --------------- eeil byl � . '----- ------------5 .------- -- ---- - 8. rt _ ----- 4- ---------- --------;0------------------------------- NSPECsTIONA.BY: ------ Date------------ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California _ LoiU California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 n .