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. 3 Permit No. _. ....�-0•-•�--- f APPLICATION FOR SANITATION PERMIT y (Complete in Duplicate) Date Issued �(-.---'.------'----- t Joaquin Local Health District for,.a permit t 'co struct and install the work herein described. Application is h reby made to the San q This application is made in compliance with County Ordinance No. 549. I - O�----- r - ---- ------- ------------------------ ---------- ---------------- ---------- ADDRESS AND LOCATION.j�e �' "`Owner's Name- - - -�----- - --------------------------------- ----------------------------------- - --. Phone---) -Q------------------ .. 1 ------------•-------•-----------------------•--- Address ---- Phone----------------------------------- Contractor's Name ----- ----- Installation will serve: Residence .0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___j___ Number of bedrooms z___ Number of baths -_------ Lot size _____________ Water Supply: Public system JZ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ 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 wel4_________________Distance from foundation__ �_.______ __.Material___- _ - o `^�OO No. of compartments--------------------Size_'..x-S--X-3---.......Liquid depth----- 14---------------Capacity Sf ------ Q Disposal Field: Distance from nearest well_ ..-Distance from foundation- 1 0 .--..No. to nearest lot line_____---.---- UC.I -----Width of trench.---- Number of lines------------- -----------------Length of each line------------------- ----- -4_r!�--------------- Type of filter material---1_R ------------Depth of filter material----1_�'--_-- Total length 1 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----------_-------------------- els. ❑ --------Depth-------------------------------------- -- --------Liquid Capacity---------------------------g Size: Diameter-------------------------- --- - - Privy: Distance from nearest well____________________ ----------------------------Distance from nearest bu;iding------------------------------------------ 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. (Signed) ______________-_____---__-______-----_-__(Owner and/or Contractor) 14 --------------- B Y.--.- - Tale (Plot plan, showing si a of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY DATE------------------------------------------------------------ APPLICATIONACCEPTED BY------------------------------------------------- --------- ----------- ------------------------ DATE------------------------------- ---------------------------- BU{LDING PERMIT ISSUED------------------------------- ------------------------------------------------ --------------------- DATE---------------------------------------------------------- -- Alterations and/or recommendations:------------------------------------- ------------------------- ------•--------------- -- ------------------------------------------------------------------- ---- - ------ ------------------------------------------------------------------- ` �^-- -- 1- --- - ------ - - ------- --- ----------------- -- --------- - -------- - ------------ --------- - -•--------- ?, N� W f -yam /' --------------Y- � �l/�f ` Date---------------/------ ---FINAL INSPECTION BY:_...._V- - .""-I . -r / 4^ - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton. California Lodi California Manteca, California Tracy, California ES--4-2M IC-52 Revised W-2100