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APPLICATION FOR SANITATION PERMIT Permit 'No. (Complete in Duplicate) _=__I-j Date Issued .7 �=___ Zr 2 - I4?o z9 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describ d. This application is made in with County Ordinance No. 549. JOB ADDRESS AND L CATION = ` `� -• --- ----- .t__ _l..d . h Owner's Name ------ -G/----•-- - --••--------------- -- -••------ ---- ------------------------ - ------------------------ Phone------------------------------•----- Address--------- Q ••- .. 1----------------- ---------------- -----------------•----- ---------------------------------------------------------------------------------- -------- Contractor's Name-•--------------------- ' ----------•-------------------------- -----•-------------------------------------------------------. Phone------------------ ----------------------------------- Installation will serve: Residence )( Apartment House ❑] Commercial ❑r Trailer Court ❑ (Motel ❑ Other ❑ Number of living units: __1----- Number of bedrooms _1 __ Number of baths J`____ Lot size -------I---61-'t`- -t'------------------------ ______ Water Supply: Public system ❑ Community system ❑ Private x Depth to Water Table __4___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No`>� New Construction: Yes -N ® o El TYPE OF INSTALLATION AND SPECIFICATIONS: 11 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Disfance from nearest well--- 0______Distance from foundation_-v-_-�`._-_.Material ` .�______________ - ' No. of compartments-----7-----------------Size-- -X-°bC_,X__j�L Liquid drrepo------3------------------Capacity-11-6 0-------- Disposal Field: Distance from nearest well_SO_.____Distance from foundation---�_i�--------Distance to nearest lot li�__t�_.____. Number oil lines__.___-1_____________________._ Length of each line-_____1_2._Q__ Width of trench..-- [J Type of filter material___._ _`'_____Depth of filter material-------J__�.___ _ _Total length----- -------------------- Seepage ________________ __ Seepa e Pit: Distance nearest well---_ f ` __ Dacefrom foundation Distance to nearest lot line_________________❑ Numbeof pi - -�fl�g � teal - Size: Diameter Dp+ _ Cesspool: material 'l Distance from nearest well from foundation----________._____.Lining material_____________-_._-_________________. ❑ Size: Diameter--------------------------------------Depth - Liquid Capacity,_ ::„-_•-_---. gafs. Privy: Distance from nearest well-------------------------_-----------------------Distance from nearest building__________.___________________-._ ❑ Distance to nearest lot line -------------------------------------------------------------------------------------�-------------------------------------------------- Remodeling and/or repairing (describe)___________________ --------------------------------- -----------��"-------___ -------------------------------------------....---------------------------------------------------.---------------------------------------------------------------------------------------------------- ------ - 1 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. � k (Signed) <�"� s '----------- ------------ ------------------------------------------ --- [Owner and/or Contractor] By:--------•------------t ----------------- -------•--------------------------------------------------------------------(Title}------------------------------ (Plot plan, showing size of lot, location of system_inLr-elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY .00 APPLICATION ACCEPTED BY------------- ------- -------- ----------------------------------------- DATE u----------------------- t- - REVIEWEDBY------------------------------------------------------------ QATE -------- BUILDWG PERMIT ISSUED - - ( -- --------------------------- DATE----- ---------------- ----------------------------------------------------------- �; Alterations and/or recommendations-----------------------------Y--- ecommendations--------------- --- I --- - - ------------ -------------------------------------------- --- -------------------- ---------------- ------- ------------------------------------------- f-------------------------- FINAL INSPECTION BY--------- -------- ------------------- --- f - 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