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t � ...... 'I APPLICATION FOR SANITATION PERMIT Permit No. ` --_®_______-.___ {Complete�� in Duplicate) Date Issued ��`'-_3 Application is hereby ma a 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. q q JOB ADDRESS AND LO ATION /- r'_-.----_. - ------ -- ��.. r� Owner's Name !rte ------- 1---•---------- ------- ------- hone---vim / q �y� Address-----------Sl_ al Contractor's Name--------- •- - .:..= ---------------------------••------------------------- ------- Phone----L___+/ - _ Installation will serve: Residence [E'Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_)---_ Number of bedrooms .3---Number of baths jot_ Lot'size _________________ ._ Water Supply: Public.system ❑„r Community,system ❑ Private Pl"'-D'epth to Water Table _T1_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam Ej Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes ❑ Now Construction: es No �f TYPE OF INSTALLATION AND SPECIFICATIONS: Al (No septic tank or cesspool permitted if public sewer is available within 20 feet.) Septic Tank: Distance from nearest well________c___--_'Distance from foundation__________________-Material ___. ' ❑ No. of compartments_- ------Size------••------------------------Liquid depth---------------------- ---Capacity------------ Disposal Field: Distance from nearest well-.�d-.__Distance from foundation__--_4rd.-____.Distance to nearest lot line -- Number of lines______________�____'I-- -- Length of each line----____7.�1- Width of trench__-41-- ------------------- Type _______._-_ --_.- W� . ,, �; Type of filter material_!__ ___ ____Depth of filter material____._ .__:_ ...Total length--------- __----------- vl 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------------------`-'---- # y _ Depth == 'x -Liquid Capaci+y- --------------------------gals. jI Privy: Distance from nearest well ______________________`____------'------------ --Distance from nearest buildingI ❑ ' Distance to nearest lot line--�------------------------------ ------- -------------------------------------------------------------------------------- ---------------- Remodeling and/or repairing (describe)----=-------------------------------------------------------------•--------------------------- A. ------------•----------------------- --------•--------,-------------------•-------------------------------• ---------------------------------------------------------------------------•••--------------••---------------- I hereby certify that 1 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}--------------- /--� --------- -- - ----- --------- -------------------------------------------------------------- --- Owner and or Contractor] By:------------------- -----=------------------------------------------------------------------ITitle) (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------ ------ --•-- r REVIEWEDBY--------------------------------------------- DATE-------------K---------------------••---------------------- BUILDING PERMIT ISSUED-------- ---------------------------- ---------------------------------------------••----------- DATE------ ------------- Alterations and/or recommendations:-------------- ------------- --------------------- --------------------•------------ -------------------------•------------------ -------------------------------•---------------- ----•--------------------- ---------------•------------------------------------------------------------------- ----------•-------------- ----------------------------------------------------•------------------------------------------------------------------------ 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 10-52 Revised W-2100