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}l� APPLICATION FOR SANITATION PERMIT Permit No. ly- f.111 ------ YA (Complete in Duplicate) Date Issued ___�a Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the w rk herein descr' ed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A CATION. - ----------------- -- --/-------- Owner's Na ---- ---- - -- / Phone - . Addres ---------------- Contractor's Name.--- -------------- !_-- --------- Phone__-_...._..3- y Installation will serve: e ' encu ftp ment House ❑ Co e al ❑ Trailer 0 urt ❑ Motel ❑ Other ❑ Number of living units: __//____Number of bedrooms __ ___ Number of,baths __-/___ Lot size _,�_"_ s� Water Supply: Public system ❑ Community system ❑ Private Depth to Wafter Tablft. Character of soil to a depth of 3-feet: Sand ❑ Gravel ❑ Sandy �LoaA Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ Nok New Construction: ,Yes—W No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well-----------------Distance from foundation-------------------.Material_____---_--_---------_____________--______-__-_-. No. of compartments----- --------------------Size--------------------------------Liquid depth.-------------------------Capacity----------------------- Dispo al Fi Distance from nearest well-. -._Distance from foundation__ -_..De Distance to nearest lot line____. _�-_- ----••-- NumUer of lines-----I-------- ----------e----Length of each line---------- --�-____--.Width of french-------wP------ -------------- Type of filter materia _ __ _.___ _ _ Depth of filter mate ria l__.-_!____._Total length___________ --------------------- Seepage _--____________ Seepage Pit: Distance to nearest well---------------------- 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------------------------------------- F] Size: Diameter--------------------------------------Depth :-- ---------- - - ------Li Liquid Capacity----------------------------ga I S. Privy: Distanced,rom nearest well______ ----------_------------------------------Distance from nearest building------------------------------------------ El Distance,to nearest lot line-- "` -------------= = - -------------- �--?' = �--ids.. ----------- Remodeling and or repairing (describe):__ _ A _ .__._.__-4_______ _�-__ ........ .......... ••--•-.•-------•----------- - - -•-----•-• -----• •-- .--- ---•-- •------------------••----•-•----•-------------•--•-------•-------------------------- + - ---••---------............-------•-------•-•----------------------------------------------------•---------- ---------------- ---- -------------------- ------------------------------------------- ----------- I hereby c ify that I ve prepared this plication and that the work will be done in accordance with San Joaquin County ordinances, a laws, an ul s and regulations of the San Joaquin Local Health District. .0� (Signed)----- --------- ---- ---- r`� ( / } a--__. ___ _ `� __ ______ ______Owner and or ontraefor By:-------------- _ ---------------- ---------------------------------------------------------------------._.(Title " - (Plot plan, showing size of lot, location of system'in relation to wells, buildings, etc., can be p ed on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY5Z-'---- ------------------------------------------- ------------------------------------------- DATE-'------------------------------------------------------ REVIEWED BY - QATEi�.`------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------- -- ------------------------------------------------ "Alterations and/or recommendations:----------------------.--------------------------------------------------------------------------------------------------------------------------------------- -----------------I---------------------------------- ------------------•------------------------------•---------•---------------------------------•-------------------------------------------------------------------------•-------------------------------------------------------_-----------------------------------•---- ----------------------------------------------------------------------------------•-----------------------.-----------------------------------------------------------•-------- ---------------------------------------------- # FINAL INSPECTION °BY--------------------------------- ------ ---------------- Date.-- - � �----------------- --------• 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 Revised W.210O