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,; APPLICATION FOR SANITATION PERMIT` ��nit No.- it (Complete in Duplicate) �. 3 I -gate Issued�� ..._ Applica�ion 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 LOCATION.... -_d ------ ------- --------------------- -----_----- -- Qf� ,{/ --- -----------/ ------ Owne�'s Name-------- -,�`'vr`.-'---------------------'--- ----------•---------------....------------------------------------------------------------------ Phonate �"�< 4�d Address.-----------------------!9--Y6-*f--C°- '�.'i!-----------------------------------------------------------------------------------------------------/----------------------____---- Contractor's` Name ---•-------------------- Phonell)�1`1--��h,-�_7- Installation will serve: Residence [Apartment House ❑h Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units:'--/--_ Nurnb_er of bedrooms __o�'-_ Number of baths __l__- Lot size -------A__"`--_------�-�--'_________________ I _�dit. Water'Supply: Public;.system' Community system ❑ Private ❑ Depth to"Water Table r " Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes [[No E]- New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' Septic No septic tank or cesspool permitted if.public sewer is available within 200 feet.) r Distance from nearest well----- -----Dista c fr m foundation---Ze_______-.Material___�-�____ _r_4-_c_�_-- ------------ No. 'of compartments_------ .............. Size 1-_--- Liquid depth____ _ ____.____Capacity_______ J/F' Distance from foundation_-_46_____�_Distance to wrest lot line___f ______ O Disposa field: Numabeeof�lines earest well;r.--- - 'Length of each line-------�____ _ -------Width of trench_.___c i -------------------- Type of filter material-��__-_______:Depth of filter material-___._� ----------Total length__----�0---••----------• --•- C> 5eepa` Pit: F Distance to nearest�}^``ell_____�-________Distance fro fou dation-__70 -----Distance to nearest lot line 14? of pits-____.1_______._____Lining material-Q� _Size: Diameter....... 3_.___.____.Depth-----o;? ________________ 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------------------------------------------ El ' Distance to nearest lot line--4--`� -------------------"---=------- - ------------------•--•-=-•--------------------------------• - ---- ----------------------- e Remodeling and/or repairing (describe):----' '-------------- -------------------------------•--------------------=----=--------•--•---____-----••---------------•-----------••....... ... t f ----------------------------------------=------------_. ---------------------------•----------•----------------------------------------- -------------------•------•------i-----------•------------------------------------ ------------------------------------------------------------------•----- ...------------------------------------------------------------------••--------------------------- 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws;and rules and regulations oA the San Joaquin Local Health District. ------- ------ ' - --------------•----------------------------------------------------- - and or Contractor ro By::. ...... -------------------- ---------------` =---------{Title)-_. rte — (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I k + FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE-'. REVIEWED BY---------------------- ----- - DATE_- BUILDING PERMIT ISSUED-------- - DATE------IJ\,-_---------------------------------------------- Alterations and/or recommendations:-------------------------------------------------- ----------------------------------------..------- ------- --- ° --- - ---- ' - "-------�------- --------------------------------------- -- ---------- ----------------- -- ---------------------��---- F---- 5 ------------------------------------------------------------- ------------------------------ ---------- ------------------------------ --------------------- ---- FINAL INSPECTION BY:- CC Date .-�--YD � r� --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street f Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100