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I APPLICATION FOR SANITATION PERMIT Permit No. Z......... (Complete in Duplicate) f / 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 Irdinance 1. 549. ,x. �J JOB ADDRESS AND LO ATION /.__�.. , --------------------------- ------- --- Owner's Name-------------- '' -- Phone-- - Address-----------•--------*�rj---•--U).#-----. --- •---•----- . • --------- .................................... Contractor s Name................... . . ...... .. .---- _ one Installation will serve: Residence partm t House ❑ Commercial railer Court ❑ otel ❑ Other ❑ Number of living units: -_-/_-_ Number of bedrooms ..._/_. Number of baths Lot size -------------�-F..a__; ___ _(,i.. ..____---------- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table JS-77. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe[3Hardpan ❑ Previous Application Made: Yes ❑ Noj New Construction: Ye sJ No E] 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.4067_'histance from foundation---1__.0--------Material-------Ct9. ''` .....Id No. of compartments____--�_----__..Size_,:?X__'7_X.(-'Liquid depth-------- '__-_--------Capacity... Q_ ------ t Dispo al Field: Distance from nearest well Distance from foundation...(._..__.__.Distance to nearest lot line.., __..... Q Number of lines--------1._...._ _ _ -___ ength of each line______-70-____ Width of trench........ c,, _/0--._-__----9K O Type of filter material---�_r)4 epth of filter material----._f--�s---------Total length.._..... _-------------_-- Seepage - ------------_--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------------------------------------------ 171 Distance to nearest lot line-----------------------------------------•----------------------•------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------h° "� p' - ------ --------------------------------------- ----------------------------------- -------------------------------------•---------------------------------------------•----------------------------------------------------------------------------------------- --- ----------------•-•--------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------•----------------------- --------- I hereby certify 'fl have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Staterules and regulations of the an Joaquin Local Health District. �` ' s ' All (Signed)----•-. .. ..- ----- er. 1 .•-�-•. - r�-- (Owner and/or Contractor) ---------------- By:... - -----------(Title)-------------------------------------------- ------ (Plot plan, sho g s of to ocation of system in'relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------------------------------------------------- DATE........................................................... REVIEWEDBY----------------------------------------------------------=---- ---- --- -------------------- DATE---------- .� BUILDING PERMIT ISSUED..................................... DATE-----------�� ------ -- �----------- Alterations and/or recommendations: . -----------------------------------------------•--------•-----------.....---•----•---•.-------- -------------------------------------------•--------------------------------------------------------------------------•-----------------------------------.....-------------------------------------------------------- ---------------------------------------------------------------------------..-----------------------------------------------------------------------------------------------------------.... ------------------------------- S FINAL INSPECTION BY-------------- -A_ ��..�-------------. 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 10-52 Revised W-2100