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k � / APPLICATION FOR SANITATION PERMIT Permit No. Y _ (Complete in Duplicate) Date Issued Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construtf 00 Install the work herein described. i This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCAT ON----�--4ji --------- ---------------- ------------- ---------------------------------------------------•---•------ - -- ------- s,; 4 �3 Owner's Name -'•I '--- Phone- �/—!� : 9 Address----------- -- l.4...![- -J�-------- "" .-...--- ----------- -- ----- ------ ------------------------------------------------------- Iv � ---------------------------------------------------------------------- Contractor's Name_-_____��~•-- _ Phone----9.—Y-4-a-1----- Instaliation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other ❑ Number of living units: ___ __ Number of bedrooms _5�__ Number of baths ---I__ Lot size ______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Naw Construction: Yes Li' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well---!_!t_d----Distance. from,�fou da ign______�0_r___.Materi ,---- ___LJ._--- _-__-___. I V No. of compartments-----------A-----------Size r•X-YA__\1__(0.X.Liquid dep. h------�lt.--------._Capacity---__�40------- 711 ----- i Disposal Field: Distance from nearest t!L-_/,Z. ____Distance from foundation_____ --------Distance to nearest lot lir�p___S?2 d_..__ 1 *r [ Number of lines--------------------- --- ------ Length of each line------� -____-. Width of trench.--- -y_.--------------_--� Type of filter material l�e�____ _ ___ __Depth of figmo -----I_C-_.___�___Total length ________________�__._O Seepag Pit: Distance to nearest well.... p�------Distan rn ______._.Distance to nearest lot line________-__ [y Number of Fits-------/------------Lining mater' I__ iameter----- s .----Depth----o -.---Cesspool: Distance from nearest well_________________Dista on._..--- ---_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)----------------------------------------•-----------••----•----------..----------•-----------------•-•--- ---------------------------------•------- ------------•----•--•--------------------------------- ------------------------------------•-------•-------------------------------------------•------------------------•------------------------------------------------- ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------•--•------•-------••------------------------------------ --------------------------------------- ----------------•------------------------------------••---------------------•••---•----------------------------------•-------------------------------------------------------------••---------- •---------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, ti.d rules and regulations of the San Joaquin Local Health District. (Signed)---------------- ------ --------------------------------------------------------------------_I*mw 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). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- ------------------------ ----- - DATE..-. ---- -• .- � -- REVIEWEDBY-------------------------------------------- -------------------------------------------------------------------------------- DATE-------------------•---•------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------------------------------------------------_------ Alterationsand/or recommendations:-------------------------- ------- --------------------------------------------------•------------------•----••----•---•-------•--------- -----------•--- -------•----- ---•-----------------•-------------------------------------- ------------ --------- --------------------------------------------------------------------------•-------------------------------------------••-- ----------•------------------------------------------------------------------------------------------------------------•----------------•--------.--------------------------------------------------------------------------. FINAL INSPECTION BY---------- -------------------------- Date--------------------------- ------------------------------------------------.... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : ' Revised W-2100 e