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/I IUy,� 4-4-k APPLICATION FOR SANITATION PERMIT Permit No. _o�_��._q__ (Complete in Duplicate) Date Issued`_��____ 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. JOB ADDRESS AND LOCATION----------------------`. -h-- "�r-r --- '��----- ------`-------------------------- Owner's Name----------------/ --- --•---------- . -------- ---- -------- one------------------------------------ Address_..----•--------------------------------ry---J----------,--------------------------------------------------------------------------------•--•--------------------------------------------------------------- - Contractor's Name--------------------5 -- ------ --- ---- -------------------------------------------------------- ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trrailer Court El Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms _�mber of baths[-___-_-- Lot size -----�_�_3__�_'�'�`d_________________-_ Water-Supply: Public system ❑ Community system ❑ Private epth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ay Loam ❑ Clay ❑ Adobe%N;rl�pan n Previous Application Made: Yes ❑ No U,—Wew Construction: Yes 9 LJ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)I eptic Tank: Distance from nearest well__,F __ _ istance from-foun ation___1 A____(____-Materi --- ---------------- No- of compartments_____________ ______�_ ��--(,-Liquid de th-_--_-_- •�� --Capacity--------�- ------_------AIIA 1 Disposal Field: Distance from nearest w lL�`_`_b_____Distance from foundation------/__d_____-Distance to nearest lot line--- ) Number of lines--------------- ------ ------------Length of each line__ 1�"" V 0 Width of trench_______-__-�1-/) Type of filter material # `t__ ___�Depth of filter material_______ ___ g Total length ---- f1 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. (Signed) r._ C !.�__. `' � F -----------------------------------------------------------(Owner and/or Contractor) ------- By:-------------------------------------------------------------------------------- -----------------------------------------------(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 DATE 5 ---------- REVIEWEDBY------------------------------------------------------------------------------ ---------------------------------------- DATE------------ ------------------------------------- BUILDING ------------ -- ----- - -- BUILDING PERMIT ISSUED-------------------- --------------- DATE------ 1------ Alterations and/or re�opmendatio�ns:___- -�-—-------- - -- - --_- -- -�---- 1l_-__ -'_"'''�------ ---------•--- iE�- ----.4a- '}x ' ----------------------------------------------- ------------------------------------------------------------------•------ ------------------------------------------------------ ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------•-----•--------- ------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ----------------------------------------------------- FINAL INSPECTION BY:--- � _______ Date------9rPJ "A— - _ _ ----------------------------------------------------------- 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 ES-9-2M 8-51 Revised W-2100