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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) �q Permit No. __ Shc._.----- Date Issued --- _l/f . ----------- 4 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 CO y_rdinance No. 549. JOB ADDRESS A LOCATION -----•7" _ �'' �l 17 % ?res r,;': t ------------ j�--/_---------- ---------- I ° r �_'L /-- �? '�+ �•rr ` '` Phone! ` '7"`0Z C-_ Owner's Name__._ /,1 y'-.,1 Address----------• ---19---zl, ? .._ ., , r� ...4� - ----------------------------------------------------•-••------------------•------------------------•--- Contractor's Name: I - G-- --- -•-----------•---------- ---• --- - -- - --- ---- - ..-Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo!PI [❑ Other ❑ Number of living units: _I___ umber of bedrooms--- Number of baths ___1___ Lot size 4 �_--_________________________ Water Supply: Public system [S7rFmunity system ❑ Private ❑ Depth to Water Table ________ ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamClay Loam E]Clay ❑ Adobe Hardpan E]Previous Application Made: Yes E]No IF( New Construction: Yes ):No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted .i� public s wer is available within 200 feet k4w��,4 Septic -Tank: Distance from nearest well____ ____ _____ADistance� fro ,fou tion___ __e_.Material___.._____. No. of compartments-_-_--ze-0 L7__KP� ..x_ _ _--Liquid depth_ ------- ------____--Capacity-- -- - --�-- _ F Disposal Field: Distance from nearest well____ _.'00istance from foundation_40_�istance to nearest lot lin __x.07 +* // t Number of lines ___._____., - Length of each line __________✓ __{ Width of trench_._____/ _i-____________ ' e rf F Type of filter material___ _. of filter material-_ ---- �__.__f_____Total length______________________-_ Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest lot line __.__.__-___-____ ❑ Number of pits---------------------- Lining material ----------------------- Size: Diameter ------------------ ----- Depth --------------------------------- Cesspool: .----------------- ------Cesspool: Distance from nearest well --------- _------- Distance from foundation.. ------------------ Lining material ------------------------- __.__.__.. {��\ ❑ Size: Diameter--- ------------------------------ Depth ---------------------------------------------------Liquid Capacity -----------------------------gals. 1w� Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ------------------------------------------ l" ❑ Distance to nearest lot line --------------- --------------------------------•--------------------- .I.`T.. . Remodeling and/or repairing (describe):------------------------------------------------------- -------------------------------------------------------------------------------------------------- I -, ----•------------------------------------------------ -------•------------------•---•----------••----------------------------------•-------------------------------- ---------------------------•-------------------------------------------- =-------------------------------------- ----------------------------------- ---------- ------------------------•-------------------------- -----------------------------•--------------------------------------------- ...-..•--•------------------------------------------------------------------------------ -------••------------------------------------------------ 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)-,_ -- _----.-------•------------------� �,/� �-��.1r5�fi�._±_�vyOwner 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 BYK-------------------------------------------------------•----------------------------------- DATE= ----•---•---------------•------ REVlEWEDBY --------------------- -------------------------------------------------------------•-------------------._ DATE_ ------------------------•------------------------ BUILDINGPERMIT ISSUED ------------------------ -----•------------------------------------•--•------------------------------- DATE--- -------------------------------------------- Alterations and/or recommendations----------------------- ----------------------------------------------------- .------- _ ------ ----------- ------------------------------------------------- ------------------------------------- -------------------------------------------------•-------------------------•----••----------------------------------------------- ----•-------•-------------••-----------•------------ --------------------•--------------------------------------------------------------------------------------------------------- •-------------------------------------------------------------------------- ------•-•----- -------------------•-----•---------------- ---- I ----------------- --------- -------------------------•----------------------------------------------------------------------------------•----------------------- FINAL INSPECTION BY ------------- ------------------------------------ ---------Date�1 ------. .- ---------------------------------------- ----------•------------...._. 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-2100