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'Y 7 APPLICATION FOR SANITATION PERMIT Permit No.._.-�_l-:0.-.______ (Complete in Duplicate) Date Issued 5-1-Application 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. ' JOB ADDRESS AND LOCATION--------- ---- -- -- - ----� t �---�------------•--- --- -- -------- Owner's Name_- = -- ------------------------------------------------------ - Phone---'7" - �`� ------- �' �, Address------------- �( -------- �`�'[� Contractor's Name--------------- - ----------------------------------------- ------------------------------------------------------------ Phone-----•------------ Installation will serve: Residence- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms .a - Number of baths _�_____ Lot size __- _ - -_`2..a___�C____ __o_____°_________-_ Water Supply: Public system [R--Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe[ ar an ❑ 1 1 Previous Application Made: Yes [Z]-No New Construction: Yes No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest Distance, from foundation_. .__________.Materia4_______________'z------�,sem�s _______________ No. of compartments._______�____________Size__J _ __ _ __'1_�......Liquid depth___3 �_______.___Capacity____s5--�__a_____ Disposal Field: Distance from nearest welly .Distance..from foundatior�---1x__1._______Distance to nearest lot lined------------ h Number of lines__________,._-_-______ Length of each line_, 1,47 JJ! Width of trench---S�__ _____________-_-------- Number �------- Type of filter mate rial__ ________Depth of filter material__.__If____________Total length----- ____I _Q________ Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line__________ ❑ Number of pits----------------------Lining material---------------_-------Size: Diameter------------------------Dept h--------------------------------- 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----------------------------------- 171 Distance to nearest lot Iine----------------------r---------------------------------------------------------------------------------------------------------------- Remodelingand/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).-----=-- ----------------------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) - ---------------------- k r r'` (Title) ------------ I (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------------- ------ ---- -- ----- ------ ---------------------------------------- DATE--- ------------------------- --�--------- REVIEWED BY------------------------------------- -- - -- DATE--- " ---------- ---- ---- --------------------------- ------------ 1 BUILDING PERMIT ISSUED------------------------ ------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:-__ !1` -Xfo_______�[�__b.�_... . ------ -- ----------- r s - ----------------------------------------------------------------------- -------- -------------------------------------------------------------------------------------------------------------------------------------------- 4 ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________.._.-__.__..-.-_______-__________.____-_-__-_______________._.____.__.____________----- -----__.___.---_---------------------------------------------------------.______-___________________________- F FINAL INSPECTION BY: --------------- Date--------- ---------------------------------------r------------- -2-------------•-r-- ------r------"---- -------------•--- 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 8-51 Revised W-2100