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r ` APPLICATION FOR SANITATION PERMIT Permit No. v -------- (Complete in Duplicate) Date Issued,Yid,,cr - `X J plicatit5n is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heribed. isapplication is made in compliance with /County OrdinanceeNN . 549. JOB ADDRESS AND LOCATION_____ -Cf1- ----- ;-r-• O --- -- ------- VC-1),14 /p �} Phone- Address hone Owner's Name---------_Y-C_.�.1•�-•--------��----------(,/Uml��-��`----------------------------------------------------- - � � I Address--------------_------ -- ----_------------------••----------------------------------------------- ----------------------------- b �/wrj,f L7_--------� �-/�� Ph Contractor's Name--•-------- o,_4 one �� e' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ " Number of living units:Ote_,Number of bedrooms _�� Number of baths __/____ Lot':size ___ ------------------------I-----.- Water Supply: Public system ❑ Community system '❑ Private W Depth to Water Table ZV ft. w Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ElAdobe Nt Hardpan E] Previous Application Made: Yes ❑ No A New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: 'Distance from nearest well------------------Distance from foundation---------------------Material------------------------------ ----------------- .. ❑ No. of compartments---------------.-----------Size------------------------------ Liquid depth--------------------------Capacity------------ Disposal --------Disposal Field: Distance from nearest well_ _____..-Distance from foundation__,l0-_---------Distance to nearest lot line____.-__--___ 4n—^X— �/� _ Length of each line---1 --------------------Width of trench-- - ��--•--------------- r ) ' Number of lines---- f -Depth of rr -- ---- - � � Type of filter material/ - filter material___- ______-__.-_Total length___ ,. `_____________________________ i b1 Seepa e Pit: Distance to nearest well__ erl -------__Distance f orn foundationfe��__..__....Dista�ce to nearest I t line_ `______ Number of pits_f�-_�__A_6_)___Lining material___�Iq_l�l�-Size: Diameter__O�.--------------Depth._o21.r�________---________ Cesspool: Distance from nearest well------------_----Distance from foundation--------------------Lining material___.__--_---________._____________-* ElSize: Diameter-------------------------- ------Depth-------------------•--------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----_---.----------•--_-----------------. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------- ------------------------ i Remodeling and/or repairing (describe) ---------------- -- --- - --- ----------------------------- -------•---------------------•------•------------------------------------------------------------------------ = ----------------•------- - ------ ----- ------------------------------------------ ---- - --- - -------------------------------------------------•---- ----------------------------------------------------------------------I-------------------------- I hereby certify that I have pr ared this application and that the work will be done in accordance with San Joaquin County ordinances, St a aws nd rules`an ' regulations of the San Joaquin Local Health District. i F . - ------------------- (Signed) / '------------ - -----(Owner an or Contractor) - - w (� ir2 By: '-� {Title) f' -------------- /t- - :tH i (Plot plan, showing size of lot, location of system in relafi to wells, buildings, etc., can be plat on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED-BY---- ---------- - -- ------------------------------------------DATE -- ----- - - ---- ______:_ REVIEWED BY---------- ----"DATE----- -- BUILDING PERMIT ISSUED--------------------------------------------------------------------- -------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------------- I - ------------------- 3 ____________________________________________________•__--------------- __ ---------------------- . e _______ FINAL INSPECTION BY:-------- ----------- Date ----- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES=9-2M 8-51 Revised W-2100 it