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�"o '°� - l 'APPLICATION FOR SANITATION PERMIT ,: t� ` t (Complete in Duplicate) 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 Ordinance No. 549. JOB ADDRESS A LOCATION___.__ __.Z_-V----_ .- ' - ------- --- -a � ---p------------ Owner's Name--- ----- ----- Address ----------------------------- - --- Phone-- ----------- ------ -•------- --1------------------------ ------ Contractor's Name________________________ -------- ----------------------------------------------------------- ------------------------------------ ---- -- Phone---------------------------------• Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel [I Other ED Number of living units: __--Iumber of bedrooms'---Z- Number of baths __l___ Lot size __749__ �Q- _ Water,Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam ' Clay Loam E] Clay El Ado �ardpan ❑ Previous Application Made: Yes El No New Construction: Yes No ❑ TYPE OF INSTALLATION AND. SPECIFICATIONS: (No septic tank or cesspool permitted ifpublic sewer is available within 200 feet.)l Septic ank: Distance from nearest well_ .44istance fro foundation_ Rf }}� � �� X.� U- Material T --------- _" No. of compartments �i r4� - Size -> ---- -- -----Liquid dep.�h-------------- -- --Capacity-----C-p-a7 Dispos Field: Distance from nearest w l _iNYil-.pistance from foundation____ �__D_- Distance to nearest lot lin�e/_- �___________ Number of lines___--�___- - _I------_-- _-Length of each line___--____ - g �.__ v- fr Width of trench -------Z-'T �-.---------- Type of filter mater' epth of filter material------ ----------Total length_-----•----------Z-Q------------- 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------ ____________ _ 1 ❑ Size: Diameter-------- ----------------- -----------Depth------------------- ------Li uid Capacity q p Y ------------------------gals Privy, Distance from nearest well-----_--------- ----------------------------------Distance from nearest building ---- ❑ Distance'to nearest 4.1ot line---------------------------- ---------------------_---------- Remodeling and/or repairing (describe):________________________ I hereby certify that;l have-prepared this ap lication and that the work will be done in accordance with San Joaquin Count ordinances, St a laws, and ules and regulatd`0 f the San Joaquin Local Health District. (Signed)------ e --- -------- Ow - $Y:--------------•------'-----------------••-----••-��------------- ------------------ - (Owner and/or Contract -------------------------------------------(Title)------ - ) o Contractor) (Plot plan, showing size of lot, location of system.in relation to wells, buildings, etc., can be placed on reverse side). 4 !± FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- - - - DATE _ - REVIEWED BY_ DATE ---------------------------------------------- BUILDING PERMIT ISSU,ED----------------------------- -------- DATE----- -•- Alterations and/or recommendations:-------.__.___---_- --------------- ------------••---------------------•-------------•------ ----------------------------------------------------------------------------- •-------------------------------------------------------------------- -------------- �!'i FINAL INSPECTION BY:------ / �/ -(/-- ----- --------------- Date--- ---- L-- � ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Sau1b emerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sttrea Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100