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APPLICATION FOR SANITATION PERMIT Permit No. ` (Complete in Duplicate) ! Date Issued /! � 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 LOCATIO ___.____ !- , ..C -- 1'p�. -------- Owner's Name-----�_ !_g �"' J /�_*r-. :s _-- ' ' ------------ Ohne'_---- _ 4/ ^ -------------- Address------------ -- ---------- -- - -------- ------------•------------•- Contractor's Name `.r{J-, 2:--,�-1� -- ` ----------- ------------- ------•-----•-------------• ------------ Phone---...._..---------------- •- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel (] Other ❑ Number of living units: ____/___ Number of bedrooms __/... Number of baths ________ Lot size Water Supply: Public systems Community system 0 Private ❑ Depth to Water Table ______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ' Clay Loam ❑ Clay ❑ Adobe .Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ' No E]TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • t Septic Tank: Distance from nearest well_/)-------_-----Distance from foundation- on___ AD--------.Mat No. of compartments------- ,-----------= _�-�'---Liquid depth____ r--------------Capacity--- Disposal Field: Distance from nearest well__............... 10 Distance from foundation___1� ------Distance to nearest lot line____-f Number of lines_---------- Length of each line____ - l-- -_------- - Leng 4-40-- --------------Width of trench �,- �---�- ------------ Type of filter material_S_ajfr,_--� of filter material ----I P_'�______.Tot al length___. _-,0 • ---------------------- -- Seepage Pit: Distance to nearest well---_------------------Distance from foundation-------------------.Distance to nearest lot line----.______-____- ❑ Number of pits_-------------------Lining material-----------------------Size: Diameter------------ ---------Deptk----------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__ ""-_-.-__--____---__-_- El ---- - Size: Diameter----'--- ----------- --------------Depth-------------------------------------- -- ` 1 -------Liquid Capacity- �-------------------------gals. Privy: Distance from nearest well_____ ___________________________________Distance from nearest building' 9 ❑ Distance to nearest lot line------------------------------------------------------------------- Remodeling and/or repairing (describe)______________________________________ 1 - ----------------•----------------•------------------- - -----------------••--------------•------ - ----------------- ___ _________________.____________ _.______________.___._.______________.._.__..._____________._._____________.________.___._______k____________.__.___.___________.____________,__________ I hereby certify that I have prepared this application and that the work will be done in accordarite with San Joaquin County ordinances, State laws,-and rules and regulati s of the San Joaquin Local Health District. � w4f (Signed)__ --------------{Owner and/or Contractor ------------ By:---------•=•'•----------------------------------------------•-•--------------------------------------------•---------------------- Title ) (Title) ----------------------•-------- ----------------- (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____.-____ _ ._ K ' = ---- -----= DATE= `= •= -' --- ------ REVIEWED BY '" ` ------ -------------------4-'`----="------------•---------------------- DATE-------- ------- BUILDING PERMIT ISSUED f :` --- ---------------------------------- ----------------------------------------------------- DATE: '------_-- '_ Alterations and/or recommendations:____.__._____- ---------- I., y -----•------------------•--'---•- . a ----- t -••-- -------- it -------------- ------------ ----------* - .. ._ --------------------------------- ------------------------ ----------------------------- t ------------•- I=INAL INSPECTION BY. -------------- -----------------•--_-- — -------------- ------ Date------. --------------------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street 300 West Oak Street } i. i 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California -ES-4-2M ; ' Revised W-2100