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i �V APPLICATION FOR SANITATION PERMIT 2 Permit No. _____________ t 3 (Complete,in Duplicate) e t. ;' Date Issued 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 LOCATI N______________ _ --- --Owner's Name-----------• ---- -- - - - ------ ------ .% � ------__ Phone--------- -------------------------- I AddAddress------------------------------- _ — W ..I ress --------------- ---------------------- 7----------- -------------------------- Contractor's Name--------------- k__ '�` E'/1 +f,t -' -�. Phone------------------------------ ------------ - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /.-- Number of bedrooms _ ____ Number of baths ---/. Lot size ___ -----��-^ ,0------------- Water Supply: Public system X Community system ❑Private,❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe Hardpan ❑ Previous Application Made: Yes-F] No•k New Construction: Yes.k 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-we' ll_I1l_67Y1C Distance from foundation____ _ I1 _ ��--=---•--� _---tonal No. of compartments-----------� S'zegr �--------------- -Ca acitY e Irk ,.. p Number o: lines_________ tante from foundation___. Distance to nearest lot line Disposal Field: Distance from nearest we{i_ _' ��i*f "-- J� N �_r___1°�.___ Length of each line--------6___._r Width of french.______._k Type of filter materiale-_t__.=__-- Depth`.of filter material------ __ -----Total length_-_-----tG_D__ __/_____________ Seepage Pit: Distance to nearest well__________________ D�isfance from foundation______________.___.Distance to nearest lot line______.___-___-- ` LD ❑ Number of pits----------------------Lining mat`,i atri}I-----------------------Size: Diameter-----------------------Depth------------------------ Cesspool: Distance-from nearest-well--------------—Distance from foundation-------------------.Lining material__.___-__...______--.--___._________ ❑ Size: Diameter-----------------------------&%I__!t_ Depth--------------------------------- -----------------Liquid Capacity---------------------------gals. +. Privy: Distance from nearest well.___-_---_-._ _^^^-� Distance from nearest building----_________'_______________._____---_. ❑ Distance to nearest lot. line - "`=g ,,.. -\) . ..-.-----+---------------------------- ---- -------------- i € Remodeling and/or repairing (describe):_ ;' e �"�` �� v .` rv �—r , �w r -R_ 1 r ---------------- ---------------- + _________________..-______._______._-________�_-..____________.________-___-______ ____________________________________________5__._...._.__.____--------------- _-_----r..___._._______f'_ A_______�._fi-------------- --------------------- .._ ------------ --__.___-__ {•`� r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 3 , ordinances, State la , and rules and r . ula'ons of the San Joaquin Local Health District. (Signed)-- --- ----- --------- ---- --- -------------------------------------------------------------------(Owner and/or Contractor) Y 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 BY--- --------------------- / DATE-/- --T- . REVIEWEDBY - ------------------------------------------------------------------ DATE - BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------- Alterations and/or recommendations:------------------------- -- ----------------------------•--------------------------------------•------------------- -----------------------------------------------•---------------------------------------------------------------_------------------------------------------------------•- ---------------------- •------------------••--------- ---------- --------------------------------------- ------------------------------------------------------------------------------------------- --------------------- -------------------•-------------------- ------------------ -----------•--------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ---------------------------- FINAL INSPECTION BY:. `"f "' - ------------- L- Date_----- -._� r--------- `.) SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M I0-52 Revised W-2100