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r i APPLICATION FOR SANITATION PERMIT Permit No. -- --- --- - ,Io (Complete in Duplicate) I Date Issued " ---- r'�,,' 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 County Ordinance No. 549, .r� JOB ADDRESS AND LOC` N--------------- = .a - ----- - ----- - - ----------------------'�� ----�---Owner's Name------------ ----------------------"U'-- -�G-AQ ---------------------------------- --- ' Phone--- -- Address , * Contractor's Name------•-----------•---•____--- ----------------------------- ---------4) ------•--- Phone - - -------------------------------- Installation will serve: Residence [ Apartment House E❑ Commercial ❑ Trailer Court ❑ 'Motel ❑ Other ❑ Number of living units: Ex of bedrooms ----'?!! Number of baths _____ . Lot size --------- ___ Water Su %' -�------------------ u Supply: Public system ❑ Community system ❑ Private [ADepth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [ Hardpan ❑V Previous Application Made: Yes ❑ No [< New Construction: Yes * No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:. (No septic tank or cesspool-permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__ 6--- Distance from fcuwlation____��_- _ ..------ No. of compartments------------ ------Size--- " _ --------Liquid depth-________ Capacity b Disposal Field: Distance from nearest well----- ---.Distance from foundation------- _P------Distance to nearest lot line__________ Number of fines _ `y, Length of each line_/ -- �_-/ ��Slidth of trench_--__ ___ _ ------------ Type of filter material.__ __�_ _ t,bepth of filter material------ � ---Total length-- --�_��---------- ------- Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot line------------------- Number ❑ of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth----------------------------- 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)_------------------------------------------------------------------------------ ------------------ ---------------------------------------------------------------------- -----------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------- I 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. (Si ned g )------ -"_- -------------------------(Owner and/or Contractor) f By:------------------------------------------------------------------------------------- ------ --------- - - - --------------------- Ti#I p ---------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__________ !� r ----- ---------------- -------------------------------- ----- -- DATE -- --- E IEWED BY------------------------------------------------------------------------ - - -- ------ DATE --------------- BUILDING PERMIT ISSUED--------------------------------------------------------------- ------------------------ DATE Alterations and/or recommendations____________________________ - --------•---------------------- -r ------- ------------------------------------------------------------- ----------- --- FINAL INSPECTION BY:__.___ _._ - ' -------------------------------- Date------ ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Arnorican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California ! Ivlantaca, California Tracy, California ES-9-2M 8-51 Revised W-2100