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i AN 'ATION FOR SANITATION PERMIT (Complete in Duplicate) p• } 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 LOCATION.----------lam- Lam' --------------- --- - -------------------------------- Owner's Name-------;-----------—-5 ° -< .r Phone--------------------• - - ----------- Address. ------------------------------------- Contractor's Name--------------F✓``" ------ -----------------------------------------------------------.- Phone----•--•-------------------------- installation will-serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1------- Number of bedrooms ____�_ Number of baths ____/___ Lot size _____v=§77yX___1_,;61~___________--_________ Water Supply:=,P.bl c system �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 EEJ,�a`rdpan ❑ Previous Application Made: Yes ❑ No Zjs''ICIew Construction: Yes P_-t\fo n 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_ e. .Distance from foundation__-I_Q!---------Material-------- ___ +, No. of compartments---------- -1�______Size__� �_'►__------Liquid depth________�-________Capacity----- 4)" _ ,pisposal Field: Distance from nearest well__N�'Yl_q.,_.Distance from foundation-"---- to nearest lot line______"___ Number of lines_____________ Length of each line___ ------ t e -•------ ---- g � ` Width of trench ----— ------------ Type of filter material_ x_� _____Depth of filter material___ __ k______.__Total length------.. _ la ___ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Q ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------ -------------l=----------- Cesspool: Distance from nearest well___________� -Distance from foundation--------------------Lining material______--____-_______--_____._________- I Size: Diameter--------------------------------------De th----------------- ------------------------Liquid Capacity----------------------------gals. _ Distance from nearest building---------------------------------------- El -------------------------- ____-.❑ Distance to nearest lot line______________ "'__ ___-_ _ ______ _ - "' 4 IRemodeling /or repairing (describe):--------------- ------------- --------•------------------.------•-------------------------------------------------------------- ------ I ---------------------------- ------•-----------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------- i ----------------------------- -- ------•-------•--•----- --------------------------------------------------------------------------•----------------------------------------•---------------------------------------- -----------------------------------`----------------------------------- r I hereby certify that] 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. ( g p-------- ----- t (Owner and/or Contractor) S - 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 1 - . r APPLICATION ACCEPTED BY--------------------- `---- ----- ---- ------------------------------------------ DATE----------- -�- ---------------- :�, REVIEWED BY ----------------------- ------------------? . ------------------------ ------------------------------------------- DATE BUILDINGPERMIT'ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------- -- 1 Alterations and/or recommendations__________________________________ ___________________________________ _________ - _____----__..______-__-_-_-__.___________________________________- __________ ___________ . \ ________________ _ ____._________-_-______-- __ -_._-_--__________._ -----1'50� ------ --------------- t-- --=--A -----�-� �- = L ___________________________________________________________________ - ______ ________________________.____________.___--______.___________-_________ FINAL INSPECTION BY:- - ------ ------- : -> Date---------- -------------------------------------------------------------- SAN JOAQUIN'LOCAL HEALTH DISTRICT 130 South American Street f` 300 West Oak Street 132 Sycamore Street 814 North "C" Street � Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M B-51 Revised W-2100