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\N APPLICATION FOR SANITATION PERMIT Permit No. 't. __ (Complete in Duplicate) k Date Issued 0_r:4an:U t..c Application 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�ounty Ordinance No. 549. JOB ADDRESS AND LOCATION.-�ii� --_6- i-_S_ `h_ Owner's Namme.._I _ --------•-•-••--- --• _ ----- --------- - ---- --•-- ----------- Phone------WQt-�------------- __ .Address------ �0--- Ea ± Contractor's Name------------------------------------- ------------------------------------------ ---------------------------- ------------------------------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.1---- Number of bedrooms ---I---- Number of baths ---I----- Lot size ---------�O /_X/00 r ---- ------------------------- Water Supply: Public system ❑ Community system ❑ Private 14 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No JZ New Construction: Yes ( No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) r Septic Tank: Distance from nearest well _If-�-__-Distancefrom fo�ndation---_2-U_._.......Material__C_�_i-i�i2l��__��p.0 Jai No. of compartments----- - -----�--Size-------- --�-�-.--X3---------Liquid depth-------`-�'------ ---.Capacity----P0�----- Q Disposal Field: Distance from nearest well.....4-J�---- Distance from foundation._____ _ ___ __._.Distance to nearest lot✓gine__-��_______. �► Number of lines----__.___ -_--- --Length of each line_��'_'__�� Width of trench .�-- -------L-�---------------- Type of filter matenaL_ o-r-fC__-.---.-._-Depth of filter material----Ie--------------Total length_...._...-�©------_------------ Seepage Pit: Disfance to nearest well---_-----------------Distance from foundation-__...-------.------Distance to nearest lot line------------- ' ❑ Number of pits----------------------Lining material-----------------------Size: Diatneter-----------------------Depth-_ ------ Cesspool: Distance from nearest well-----------------Distance from foundation----- .-------------Lining material---------------------------_--------- ❑ Size: Diameter Depth !Liquid Liquid Capacity- --------------------------gals. Privy: Distance from nearest well_______________________________________________.Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-- - R Remodeling and/or repairing (describe):_,-------------------------------- ---------•-•-----•-------------•----------------------------------------------------------••---- ------------------- -----------------------------------------------------------------------------------------------------4_-_--__-_.----_--__--....--._-_----_-___--_----_--___--_-__-_-..-..--_------_------_-----..-----.-------_--.-..____ _-' 4. --------------------------------------------------------------------------------------------------------------•.__-_------_---_______..___.-.-----_-_•_--•---.-----.----____-__-__--_-.__---.-._.----_-_--.---_ ..---• e ----------------------------------------------------•-------. ----------•-----------------------F----------------------'-------------------------------------------------•------------------------------------------------� 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la sand rules and gulatif the San Joaquin Local Health District. E � � (Signed)- ------ -- ---- -- (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). x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---------- ---------------- ------------------------------------------------ DATE---- ~/--3--__- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE - BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------�_1'-----------------•------ ---------------------------------------------------------------------------- --------------------------------- ------------------------------------------- -----------------------------------------------------------------------------------------------•------------------------------------•--- i ---------- FINAL INSPECTION BY---------------- ---------------------- Date- 211- /-`5--`-I-'�----------------- 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 fo-52 Revised W-2100