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-A APPLICATION FOR SANITATION PERMIT Permit No. �__�`�--6 (Complete in Duplicate) Date Issued ___5 (01 D�U.- 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. �/r f _ l•l r YG JOB ADDRESS AND LOCATION--.-- -- Owner's Name--- I" ---- ---------------�-``---- ----C � ---------------------------- Phone = t Addressc ��`.T V! b`+ �C a!- �' �-A--------------------------------- --------------------------- ----------- -- Contractor's Name------------ -f- ------------------------------------------------------------------------------------------------------__ Phone----------------------------------- N Installation will serve: Residence [3-"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ GSC' Number of living units: __�___ Number of bedrooms ---Z- Number of baths __t_____ Lot size ____,--fes____ _____________________________________________ Water Supply: Public system ❑ Community system ❑ Private ®�epfh to Water Table �4j ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam .'C-- lay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 2--'-New Construction: Yes El-..No Q TYPE OF INSTALLATION AND SPECIFICATIONS: No tank septic or cesspool permitted if public ewer is available within 200 feet.) <' /e Septic Tank: pDistance from earest well__p_____________Distance from foundation____I-- ____.Mater )r - No. f ` ®' No. of compartments------------<--_-------Size-------` ---------Liquid depth-------------f-1------Capacity---------------- Disposal Field: Distance from nearest eil__�+'.__ y____Distance from foundation-..- ---Distance to nearest low lin4e__ _ ______ [] Number of lines_______:_- __ __�, ___Length of each line__________________ _�__..Width of trench-------------------- ______--_----- Type of filter material_______~ _ � :De th of- filter material_______f_ ________Total length------------------------------------------ ,0? Seepage Pit: Distance to nearest well----------------______Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining mater ial-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material___-_----____-__________________-.__� E] Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy; Distance from nearest well-------------------------------------------------Distance from nearest building__________________________..___________. (] Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------- - 1 Remodelingand/or repairing (describe):----------------------------------------------------------------------------------------------------------A---------------------------------------...i ------------------------------------------------------------•------------------------------------------------------------------ ---------- ----------------------------------------------_------------------------------ ------------------------------------ -------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State lays?, and rules andr4q-gulations of the San Joaquin Local Heaith District. 4 ------------------------------------- ------------------------- ----(Owner and/or ContracfMla By:------------------------------------------------------------------------------------------------------------------------------------(Title)----------------------------------------------------------------I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F R DEPARTMENT USE ONLY I APPLICATIONACCEPTED BY------------- -- ------- ------------------------------------------••-------------------=------- DATE-------------- --------------------------- ► s REVIEWED BY DATE BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------- ---------------- DATE--------------------------------------------- --------------- Alterations ------------------------------------ -------------------- Alterationsand/or recommendations------------------------------------------------- ------------------------------------------------------------------------------------------------------•------- ------------------------------------------------- ----------------------------I--------------------- ----------------------------------------------------------------------------------------------------------- , --------------- ------------------------------------------------- --- ------------------------ ----------------- ------------------------------------------•--------------------------------------------- j --------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- --- ------- ----------------------------------------------------- ----------------------------- ------- --------------------- 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 8-51 Revised W-2100