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1G APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) yvl/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---- ----------------- ------------------------------1.1_`�---�--- !! '`' ' -- --- ------------ ------------------------ Owner's Name--•- ----- - --- ----- --------- -- ------------- r . Phone__` - 7 _�X�---------- Address - :---�-- - j —a -------------------------------------------------y------------------- { Contractor's Name------- -- .--- ----- t---- { "" ------------------------------------------------------------------ Installation will serve: Residence [P4partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ! Number of living units. _1___ Number of bedrooms j4___ Number of baths __/-_- Lot size _ __Q_--, __l__ozQ________________________________ Water Supply: Public system VIC"ommunity system ❑ Private ❑ Depth to Water Table _ V, ft. Character of soil to a depth of 3 feet: Sarid ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0-�Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes ❑ No ER I TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewes �within 200 feet.] Septic Tank: Distance from nearest well-----✓-Distance ffrom foundation---- ______.Material__ -L+__.l7"'�f8___.____- __. No.:of compartments-_______ q p, p y__ 'a�--------- Size- ra--1�`3�--X `�Li uid de th .�?-a Ca acit �Q -- � r Disposal Field: Distance from nearest we€i____�._Distance from founclation___�f__ _-_.Distance to nearest lot line_ -4�____� Number of lines-------------- _-._ __Length of each line______Aa.! . ______.Width of trench----__-ca __ �� Type of filter material..� __ __Depth of filter material------- 11'' __.__._Total length__--_-_ _------------------------- Seepage ___ ___________________ Seepage Pit: Distance to nearest well.___`-----__Distance from oun ation--------------------Distance to nearest lot line___ a__`__.n,� Number of pits---------f-----------Linin material-a- - _.- .Size: Diameter_-- 3-r�-------.De tn----�>? ----------------- Cesspool: Distance from nearest well----------------- from foundation------------------- Lining material_-_-_-______-_.____-.___-_____-______ ❑ Size. Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well________________ _____________________________Distance from nearest building------------------------------------------ [❑ Distance to nearest lot line------------------------------------ -------------------------------------------------------------------------------------------------- ---- Remodeling and/or repairing (describe)---------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Statela , and rules and regulations of the San Joaquin Local Health District. (Signed)-------------------------- ------°" - ----------- -- ----------------------------------I------------------------------------415aww and/or Contractor) By:........ .. {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 ------ -- REVIEREVIEWED --j---- --------- f WED BY--------------------------------------------------------------- --------------- ------------------------------------------- DATE------------------------------------------------ - BU1LDINGPERMIT ISSUED----------------------------------------- -------------------••--------------------------------------- DATE------ ------------------------------------------------------ Alterations and/or recommendations:--:----------- -- ---- -°----°------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------- ------------------•------ -------,---- -------------------------------------- -------------------------------------------------------------------------- ------------------------•----------------------------------------------------------------------------------•------------------------------- •----------- ------------------------------------------------------ ---- -- FINAL INSPECTION BY:-------------- 101 ?------------__ 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 I0-52 Revised W-2100