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APPLICATION FOR SANITATION PERMIT Permit No. �-Z U Ile - ---------------- (Complete in Duplicate) Date Issued -- ------ - Applica;-ion 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 Count Ordinance 549. JOB ADDRESS AND LOCATiONJL�,-),_z � � -- --------------------------------------------- Owner's Name_ �� 1� '✓_ Phone- -- 0, ' C; ---------------- Address - la ----- y Contractor's Name ------------------ •-----�M -------------------------------------------- Phone---�v_:- �0_ Installation will serve: Residence Lg Apartment House ❑ Commercial ❑ -Trailer Court ❑ Motel • l ❑ Other ❑ Number of living units: Number of bedrooms _'Number of baths ---/ Lot size -- ---------------------- afer Supply: Public system '❑ Community system ❑ Private X Depth to Water Table ------- ff. Character of soil to a depth of 3 feet: . Sand ❑ Gravel ❑ Sandy Loam ❑. Clay Loam ❑ Clay ❑ !'WobeN Hardpan ❑ Previous Application Made: Yes E]I No>�_ New Construction: YesK No ❑ TYPE OF fNSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__- 2Distance from foundation_- r -------.Material �a. No. of compartments - - - "� ,• ,� . .... p Size-- Liquid dE_th---4-8------------ Capacity.slao__;/r..w Dis l Field: Distance from nearest well--- 8--_ _Distance from fo ndation-___ --- - �_----.---Distance to nearest lot — Number of lines- I---.- _/, i �}_ '- Length of each line---L�o. -----__--Width of trench.-.__ ��___._ I /Gf/ -------- Type or filter material-_-- --.-_._7 --Depth of filter material----..-- -----__Total length-----1. --0 6 $eepage Pit: Distance to nearest well____- ---------Distance from foundation---._-_ --_-_.Distance to nearest lot line---:-.r___-----__ ❑ Number of pits----------------------Lining material------------------------Size: Diameter------------------------Depth----- -------------------------- J Cesspool: Distance from nearest well-----------------Distance from foundation------__------_._ . e - .Lining material G ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity------------------------ -gals. Privy: Distance from nearesf-well_-__....-_ ..-.`----------------- --- _--._Distance from nearest buildin g----------------------- - 9' 3❑ Distance to nearest lot line-----�-----=_----------------- ---- ------- --------------- --------- Remodeling and/or repairing (describe):--.---------------------------------- ----------------------- --------------- ---- -----------------------------------•--------- ----------- ----- -----------------------------•-------------------------- ----------------------------------------------------= "" ! here y certify that ave prep red this pplication and that the work will be,done in accordance with San,Joaquin County ' ordinances, State laws, and les and egul ns of the San Joaquin Local Health District. (Signed)-_ By: --- -- ------------------------••----=-------- --------------- Title antractor) - (Plot plan, showing size of lot, location of system in relation o wells building etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_-_ _- . 3 DATE - --------------------------- -------------- - --------------------- -------------------------------------- REVIEWEDBY ---- - ------------------------------------------- DATE --------------------------------------------- BUILDING PERMIT ISSUED - =-------- --- -••--- DATE ------------------------------- Aterations and/or recommendations:.1------------------------- I -----•------•------------------------•--•---- --- -------- ----------•------------------•--- --------- -------------------------------------------- ------------------- - ----------------------------------------------------------------------------- FINAL -- --FINAL INSPECTION BY:-./ df..► �-�.�----- � '- Date - -- ----------------- ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Scufh American Street 300 Wost Oak S+reef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : Revised W-2100