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_ 'I APPLICATION FOR 'SANITATION PERMIT Permit No. [Comple`te in Duplicate) / � 5 Date Issued ..- ---- _-` Applica+ion is hereby made to the San JoaquinLocalHealth District for a permit to construct and install the work herein described. This application is made in compliance with County Ordi ante No. 549. JOB ADDRESS.AND OCATION___ .__�__ _____ _____ ---- _ ---------•---•-----------------------�------. --------------c3..7 Owner's Name --------------------------- -------------------- --------------- Address Phone--------------I-----••---•----- - ... - - . { Address--------- --Q__ ... ------= - = -------•------- Contractor's Name------- ---••-------------------------------•------------------------•---------------------------------- Phone---•---•----•-•---------•---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ `Mofel ❑ Other p Number of living units: __ ----- Number of bedrooms _'"Number of baths ---/---- Lot size ------ ------------------- Water ------ ----------Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a dept!, of 3 ef: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Nox New Construction: Yes,�RJ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: \ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearesr well-Mb_Aj-?_Distance from foundation---1I ----------MI/aerial______________ _ _ Noy of compartments---�.-------------------5ize__��-c�__�-�•_--Liquid 'depth ,- ----------------Capacity_-�_- •_-�-/- Disposal Field: Distance from nearest well.-I') 4_.A/QDisfance from foundation._10_ ..Distance to nearest lot line_____------- fNumK&-of lines-------- _54_______________ ___ Len th of each line- .__ _�__ r__..Width of trench.___ 'Type of filter material-�CP'�t_�,, e of filter material---!______----------Total length_____ ------__________ Seepage Pit: Distance to"nearest well-------------_--------Distance from foundation--------------------Distance to nearest lot line____.___________ ❑ Number of pits----------------------Lining materia;-----------------------Size: Diameter----------,------------Dept h--------------------_------------ Cesspool: Distance from nearest well_________________Distance from foundation-----------_--n___..Lining material__.__-_____________._______________. ❑ Size: Diameter_____________________________________Depth_:________-_____ --____Liquid Capacify; .-gals. -----------------------------------------------_._Distance Privy: Distance from nearest welfrom nearest building__,__.._______________________-._.______- ❑ Distance to nearest lot line___________________________ ___________._.._______ Remodeling and/or repairing (describe) --------------------- "------•--------------------••-•----------------------------- -------------•----------------------------------- _= _---------• ----------------------------------------------------------- -• ---------------•----•---•--•-•----------------------.....---•----------•---------•-•------------------•-------•-••--.*-•--------------•--•---------•----------------------------------- I hereby cerfify that I have prepared Phis application and that the work will be.done in accordance with San Joaquin County ordinances, and rules a d regulations of the San Joaquin Local Health District: (Signed) ) �'� ---------------------------------------------------------------- -------(Owner and/or Contractor) By:------------------------------------=----------------- --� ----------------------------------------=-----`�----------------(Title)---------------------------------------------------------------- (Plot plan, showing'site of lot, location of sys em"in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - ------------------------------ DATE--- ---- - --------------------- REVIEWEDBY----------------------------------------- ------------------------------------------------------- DATE--- -- BUILDING PERMIT ISSUED._.•--•------------------- ---- ---- --------------------------------------------- -------•--- DATE------------- # Alterations and/or recommendations___________________ ___ ------•--------------------------------------N-•Q!T'i......----------- -------------------------------------•----------------•----------------------- -------------------------------------------------•---- -..---•---------------------------------------------....------------------------------ ------------------------•-----•--•-----------•--------•--------------------- ---------------------------------------------------------------------------------------------------- --------------------- :------- ------ ------------------------ -------------------------------------- FINAL INSPECTION BY: ' � ----------------------------------- Date------ + SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street F 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100