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�y ' APPLICATION FOR SANITATION PERMIT Permit No. .___�'__` __�-�___ ° in Duplicate) (Complete Date Issued - -- ---- --53 Ap licafion 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. 5.49, JOB ADDRESS AND LOCATION____-- �--�'-^_�---,00 ---R r-. — �--- -- -- -----i------------------------ Owner's Name---------------------- _ " Phone Address---------------------- `------------ - _ ------- --- Contractor's Name------- 8 �-- --- Phone y� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bed roams0:17--- Number of baths Lot size ------- _f �Q' Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table-? ft. Character of soil to a depth of 3 feet: Sana ❑ Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe Hardpan El 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.) x Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- No. of ____________________.._________________________- No. .of compartments-------------------- ize--------------------------------Liquid depth-------------------------.Capacity----------------------- 1 ._.Distance from foundation__ _ ________Distance to nearest lot line___ Disposal Field: Distance from nearest well* __.._ Number of lines__.e-- --------- --- Length of each line_____ Z' Width of trench____ ----------------------- O Type df filter material_,$',__ ___Depth of filter material----��_______-__Total length______- Q________________________ 6 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--------------- v ------ ------------- ------------------------------------- ---•------------- s 1 ________________________- ____________________________.__________________________-____ _________________________________________ ------------------------------------------------------------- _ ----- _ ----- _ ------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. ` (Signed) l� 4_� - —� --- O 8r and�fi Contractor { g ) K - ---------- -- ---- { ) 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 Z------- --- ------------------------------------------------------------------------------- DATES REVIEWED BY-----------------------------�"%�t * -------------------------------------------------------------------------------- DATE-- BUILDING PERMIT ISSUED--------- --------------------------------------------- --------------------------------- DATE-------b3----------- -----------'------------------------- Alterations and/or recommendations------------------------ --------------- -------------------------------------------------------------------------------------------------------------------- ---------------------------•=------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------•-------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ N � FINAL INSPECTION BY----------- - -----� LP--- -------------------- Date----------------'� � - r ----- ---- ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American S+reo+ 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21A 8-SI Revised W-2100