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' r Z APPLICATION FOR SANITATION PERMIT `j (Complete in Duplicate) Permit No. Q J Date Issued' -z. .._.._. Applica+ion 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____. ----------- Owner's _ Owner's NameP ---- -- ------ -------------------- -----I-------------- Address.................. --_---- � t - '�' �------------ ----- -----------•--- . Contractor's Name---------------- - -- -------------------------------------------------------------------------------------------------------- Pin - v Installation will serve: Residence partment House [:]Commercial E]Trailer Court F]M I ❑ Cher E] Number of living units: _____ Number of bedrooms -.-_ Number of baths ___ ___ Lot size ___.___*ft. l_,1.(j__! __________________--- Water Supply: Public system ❑ Community system Private (Depth to Water Table_ _._ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay K Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 9 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public c�}}se er .rnf ilable within 200 feet.) Septic Tank: Distance from nearest well 'v ►" starom f dat' i Materia C ------- '0 pyy 7/ No. of compartments -------------------------- Size llk.6uid ptlr______________ _____.____ Capacity___..__. Disp sal Field: Distance from nearest well s ante from foundatiof� 1 ---------Distance to nearest lot lino --. 111 Number of lines _._.,__._.__ Length of each line ...... f" -Q_''/ '"LO_Width of trench--__ !_ ------------------------ Type ___ _________________ T e of filter material ---6__'__."t4'4_ Depth of filter material---1---------------Total length --------- Seepage Pit: Distance to nearest well ---------------------- Distance from foundation .................... Distance to nearest lot line ------------- ._._ ❑ Number of pits --- ------------------- Lining material ----------------------- Size: Diameter__, --------------- .---- Depth -_____--_.___.-_-.____-_--____-- 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-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling ----------- -._.. 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) --.-.L ------------------------ --- --------------------------------------- --------------------- (Owner and/or Contractor) t/s BY��n------------------------------------------------------------------------- (Title) (� (PlotIan, showing size oJ_C!�,- ln of system in relation to wells, buildings, etc., can be placed on reverse side). P FOR DEPARTMENT USE ONLY w APPLICATIONACCEPTED BY ------------------------ -- - ----- ----- --------- ........................... DATE -------------_._ REVIEWED BY - DATE .... 1... BUILDINGPERMIT ISSUED ............................ __ , ..... ----------------------------------------------- DATE ----------------------------------------------------------- Alterations and/or recommendations:--- --------t------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------•- --------------•------ ---- -------------------------------------------------------------------------------------------------------------_-------------------------------------------------------------------------------------------------•-- -------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------- •----- ...---------------------------- ------------------------------------------------- ----- -- --------- - ---------------------------------------------- ---------------------------=----------------------------------- FINAL INSPECTION BY---------- ----- - --- 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 ; Revised W-2100