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S APPLICATION FOR SANITATION PERMIT Permit No. - -----------�W 7_l (Complete in Duplicate) Date Issued �..y Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heAe des ribed. This application is.made in gompliance with County Ordinance No. 549. �'�'41,.;.E.; �.r d&C16,•)A fib.. B JOB ADDRE55 AN LO, �AT)ION. - 2 �. oh_-..+� ncf�n lc�_ Owner's Name °'.` -----_ 6 PhoneC1 ------------------•------------ ----------------- ---------------- /Y--- - - ------- --------- Address --- Contractor's Name--------- - -- - ------- ----------------__ ----._. _-_ Phone_ �__6� Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- Number of bedrooms 3--- Number of baths _1___ Lot size __-- -_-_ ------------ Water Supply: Public system ❑ Community system ❑ Private I( Depth to Water Table 4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Q Adobe Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ;r (No septic tank or cesspool permitted TO blic sewer is available within 200 feet.) Se ti Tank: Distance from nearest wel --__.Distance from foundation__ ._______._.MateriCi__ =- P p No. of compartments... Liquid depth--�A.___.---__-_--Capacity Disposal Field: Distance from near�rst well--6_�'___Dista cffrom foundation_-f Qr--__--Distance to nearest lot line------'r__—�--- Number of lines-----1--_----_____ cr Length of each line--- Q� � _ Width of trench__4_��'___________._-- Type or filter material___yZ_-._P _Depth of filter material----- pp_ Total length__ �---------------------------- -� 4 _ °� See age Pit: Distance to nearest we1E_.1.00�____Distance f m oundation---_f _.__.___.Distance to nearest lot line--_-_--� r I+�) Number of pits----- Lining materia#_"&m -_ ----Size: Diameter--- -----------Depth--a._R-------------------- f7i 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.---____________--____----_._-----._-. ❑ Distance to nearest lot line------------------------ --------------------`----------------------------------------------------•-------------- , ) Remodeling and/or repairing (describe):'�_A J -- r --'•--------------------------•-----------------•---•--------•------------------------ �N ---------------•---------------- --- ----------------------•------------------------•---------------------------------------------------•----------------------------------------------------------------------------------- ----------------------------- ----- ---------------------•---------•---------------------_1-------------------------------------------------------•-•----------------------------------------------------------------- 1 hereby cer ify at I have prep ed this application and that the work will be done in accordance with San Joaquin County ordinances, Staf s land rules and regulation a San Joaquin Local Health District. 5i neo b ✓�J ! o? Ca� { g ) - -- ----------- -------�-- C tractor) ------ ------------ ------ --- -- By:-------------------------------------------------------------------------------- ---- ---------(Title)-- ---- ---`--------Im-d- A--- `-*---------- (Plot plan, showing size of lot, location of system in relat' n o wells, building etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------------------- DATE--------- REVIEWEDBY------------------------------------- --- --------- --------------------------- -----•- -------------------------------------- DATE----- BUILDING PER1vIlT ISSUED------------------------------------------ -•-•------------------------------------------------------ DATE------------------------------------------------------ Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- ------------------------------------------------- --------- ---------------------- ----------------------------------------------------- ------ FINAL INSPECTION BY-------------------------_ Date � -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 E5-9-2M Revised W-2100