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U tali 6::<o Y11 APPLICATION FOR SANITATION PERMIT Permit No. .. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct an install the work rein described. This application is made in complianc&with County Ordinance No. 549.` l r JOB ADDRESS AND LOC�TIO - '._... ---- . --------.............................. i__ _ Owner's Name- ••--••--•----•••••. ----- . • ------..... . ----- oa ----- j- - Phone--------------------------------•--- 6Address----I.6. 7 . -- --- ---- . -ile0- --------------------•----•----- = PhonContractor's Name.-----•-•--•--- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: f------ Number of bedrooms _�__-. Number of baths .._/--- Lot size0--------------------------- Water Supply: Public system ❑ Community system ❑ Private 4 Depth to Water Table /.577ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay % Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ N TYPE OF INSTALLATION AND SPECIFICATIONS: se tic tank or cesspool permitted if public sewer is available within 200 feet.) i Distance from nearest well-----------------Distance from foundation-.--......--..... Material-----------------------------------------........W No. of compartments---------- / Size---.-•-•--------------------•---Liquid depth--------------------------Capacity-_ -----------_- (1 Dispc, al Field: Distance from nearest well-©Q---.Distance from foundation---/0--------.Distance to nearest lot ine .....VO+ Number of lines--------1-_--- ._-.--- .Length of each line___.._. Q-------------Width of trench.--.Z�---------------_--- Type .------ ..----_--.Type of filter material.ST Depth of filter material----------- length----------7_0--_------------------- O Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line....-............ ❑ Number of pits------•--------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: -------------------•---- ---•--Cesspool• Distance from nearest well- .-.--..----Distance from foundation--------------------Lining material--------.------.---------_--------.-. ❑ Size: Diameter--------------------------------------Depth............---------------------------------------Liquid Capacity- ..------ --.-----.gals. Privy: Distance from nearest well _------- ---_------- -------- -- -----__-Distance from nearest building-------- _- -.. ❑ Distance to nearest lot line-------- ---------------------------------- -------------------- ------------------------------------------------• ---- ----.---- N r Remode i g and/or repairing rib - -fY-tai- -- ---------- ........... .. �d ------ ---------- -------------------------------•-------------------------I -----------•---------------------------•---------------------------------•-- •---------------•------------ ----------------------------------------- -------•------- - -------------------- ....•. -•---••--•••--•--•-•---•••--••••-•-••-•------•-----------------••--••--•-•••-•-••--------•-----••---------------- I hereby certify that I have �pared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, an rules "&4egulations of the San Joaquin Local Health District. (Signed) `-- ,, %-.-'- °----- 9 -- -�.---------------------------------------------------------------------...Owner and/or Contractor 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.----------•-- -- REVIEWED BY- -------•------------------------ ----------------- DATE---- - �I BUILDING PERMIT ISSUED-------------- --- DATE. Alterations and/or recommendations:.---.---- __`-- -------•-------•----------------------------------•------------------------------------------------------------•----------------•-------•------------------------------------------------------------------------------ ----------•----------------------------•-----------------------------------------------------------------------------------------------------------------.......--------------------------------------- --•-----•-•------ ----------------------------------------------- ----------------- ------- --------- -------•-•----------................ ------------------------ -------------..-.-. --------------------------- FINAL INSPECTION BY----------------------•- -•.......... ----- Date---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Suter 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 0-52 Revised W-2100