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APPLICATION FOR SANITATION PERMIT Permit No. �..................... (Complete in Duplicate) S Date Issued Applicaa•ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This ap lication is made in compliance with County Ordinance No. 549. M3 - 2— fp-I's-JOB ADDRESS AND LOCATION-- I � r~� ------------------ 4b-tt"-A '7 —- Owner's Name--------�- "- ,T` r�~1}c ------------------- -- ---- Phone-//49.---'��[P�j I - ------ -------------------- - -- ---- ------ --------- -- vo Address. aow_.__..--/N�-� . Contractor's Name------ ------ --- ------------------- -------------------------------------------- P h o n . Installation will serve: Residence 7�- partment House ❑ Commercial ❑ Trailer Court ❑ �Motel ❑ Other ❑ Number of living units: __J__ Number of bedroom__-_ Number of baths ___/_ Lot size ____ —-----------_______________ Water Supply: Public system ❑ Community system ❑ Private,Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel L❑ Sandy LoamClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No�` New Construction: Yes,;g,No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic ank: Distance from nearest well__ _Distance from foundation/Q-__._____..Material__G'-- - No. of compartments---:+''---------- 5ize �' ., f� _Liquid depth_s�X'.. ........Capacity ----- 63 +• 6 3„ � r Disposal Field: Distance from nearest well_�J.4. __ __Distance from foundation. ___Q_.__-___._Distance to nearest lot line_______c Number of lines____- ._`___fir_- Length of each line__-----1.53 ---Width of trench_.---pk_$�__,------------__ Type of filter material-_�-5V ___Depth of filter material__/X1'/_---------Total length-----/-00--**--------------------- ' Seepage Pit: Distance to nearest well_____________________Distance from foundation____..._________._-.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material----------_------------Size: Diameter-----------------------Deptn--------------.------------------ Cesspool: Distance from nearest well-----------------Distance from foundation__-------------------Lining material__..____-______.__-________________- [� Size: Diameter----------------------------- -- ----Depth-------------------------------------------------_.-Liquid Capacity----------------------r-----gals. Privy: Distance from nearest well ------------------------------ nearest building -_____________-____-____-------_..._. ElDistance to nearest lot line----------------------- ---------------------- -•------------------------------------•-------------------------------------------------- Remodelingand/or repairing (describe):--------- ----------------------------------------------------------------•--------•---------------- --------------------------------.------------------ ---------------------- ------------------------------••--------------------•--------------------------•----------------------------------------•--------------- ------------------------------•----------------------------------------------------------------- -------------------------------------------------------------------7-------------------------------------- -----------------------------------------------------•-----------•----------------•--•----------------------------------------------------------- ...-----------------•--•-------- 1�n --------------- ---------------------- --------------------------------------------------------------------------------------------------------------------- I ereby certify that have p epared this application and that the work will be done in accordance with San Joaquin County � ordinances; laww- d rules nd re ivrrs"o'f'the San Joaquin Local He Ifh District. S:f_LJ_�''_1 -- ------ 7_G ------- -------------- - ------ ---------------= --------- (Signed) Contractor] y� By:..... -•-------------------------------------------------- ------ - ----------- - (Title r G f 1 (Plot plan, showing size of lot, location of sys+em ' re 'on o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------ DATE REVIEWEDBY-------------------------------- - -- ----------------------------------------------------------- ------------ ----------- DATE- $�--------------- ---------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.---- �`------------------------------------------------ Alterationsand/or recommendations----------------------------- -------------------------•------------------------ -------------••---------------------------------------------•----------•--- -------------------------------------------=---------------------------------------- ------------------------------------------------- ---------------------- ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------ ------------------------------------- ------------------------------------------------------- ----------- ----------------------- -----------------------------•----------------------------------------------- � FINAL INSPECTION BY:.._ ----------- Date---------- �f_3-------------t------------=--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M - Revised W2100