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r- V APPLICATION FOR SANITATION PERMIT Permit No. ---?��- -- 4� s (Complete in Duplicate) Date Issued - ,. Ap lication 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 County Ordinance No. 549. JOB ADDRESS AND LOCATIO Owner's Name-------------------- -- - - -- ---- ------- ---------- ----- ----------------------------------------------------------- - Phone------- -----------------------•---- I Address - 2 1 y[ Q ------• ---- i Contractor's Name----- ----� � --- Phone---iv--- Installation will serve: Residence ❑ Apartment House,❑,,.,Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Lot size 4 Number of livingunits: _ _ Number of bedrooms l - Number of baths. Water Supply: Public system ❑ Community system h Private to Water Table,017ft. Character of soil to a depth of 3 feet: S;�PNew Gravel E] Sandy Loam E] Clay Loam 1-1Clay ❑ Adobe HardpEl 'an 3 Previous Application Made: Yes ❑ No Construction: Yes 4-<o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: "V (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well._!-___�---Distance from foundation---------- -- -------- -- -- - -----__-- -_---_. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well- -Distance from foundation.__j G?-___---Distance to nearest lot line.- Number of lines------—5-1------ Length of each line___,5 _A_Y-- G----Width of trench------ ------------------------- Type of filter material_! -Depth of filter material-----/_5-e -----Total length-'---/- -------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation________---._-_-___.Distance to nearest lot line-_----_------_--_ a ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h-_------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------------- _EJ _.. Size: Diameter-------:------------------- -----•-----Depth---------------------------------------=------------Liquid Capacity----------------------------gals. Privy: Distance from .nearest well-------------------------- ------------------------Distance from nearest building_-_-____------------_______-__-_-----____. ❑ Distance to nearist lot line------------------------------------------------ ----- ------ ------------------------------------------------------------ Remodeling and/or repairing {describe)-------------� vs------- �` -------------------------------•-----------------------------•------_----------------........... ------------------------------------------------------------------------------------------------------------------ " 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 rules and regulations of the San Joaquin Local Health District. (Signed)------ _)(6 "--.�1_� --!__-' A---- - ------- -�t---- -�'s� -----------------------4Own and/ r Contractor) BY: Y -------------------------------------------------(Title)-------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). "- ... ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -� n-_,`i � -------- DATE � �� --`-----------"=----- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE------------------------------------ ----------------------- BUILDING PERMIT ISSUED_----------------------------- ------------------------------•------ -------------------------------- DATE------ --------------------- Alterations and/or recommendations--------------------------------------------'------------------------------------------------------------------------------.--------------------•----------•-- ----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------- -------------•-------------------------------- --------•---------------- --------------------------------------- --------------------------------------------------------------------------------------------------------I— I ---------------------------------------------------•---•------------------------------------------------------------------------------------------------------------------------------------ --------------------------------- + ---------------------------------------------------------------------------------------- ------------ ------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:-------------------------- --------------------- Date------- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100