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b �fi � qAv APPLICATiON FOR SANITATION PERMIT Permit No. jd --- ----- �7 ✓ " (Complete in Duplicate) l /1G g� Date Issued ____ ---- --- s pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 is application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------- '!f -1N __TT.S----------------------------------------- Owner's Name--- ------------------------------- y' �C-=y-�--'f----A------------------- --------------------- Phone---- *77!ArJe -------------------------------------------------------- Phone �j 'TJX----------------------•--•----------------------------------------------------------------------- --------------------------- Contractor's Name--------,/Z a--___- - --0-d_T --- ------------------------------------------------------------------------------ Phone Installation will serve: Residence 5j--A"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J____ Number of bedrooms 2---- Number of baths 1------ Lot size ------------5-a- --------�-�-�-f1-------------- Water Supply: Public system ❑ Community system 52- Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 5;11ardpan ❑ Previous Application Made: Yes ❑ No Q�,e New Construction: Yes ❑ No [�FFiA/VA: Yes ❑ No E4---'— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tarnk,�P Distance from nearest well_________________Distance from foundation--------------------Material-______________._____--_________________________- r.. No. of compartments--- -- -------------------Size------------------------•------Liquid depth--------------------------Capacity---------------------- Disposal Fi� Distance from nearest well---------------___Distance from foundation--------------------Distance to nearest lot line_-_______________ Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------__------------------ a Type of filter material--------------_----------Depth of filter material-----------------------Total length----------------------------------------__ e Pit: Distance to nearest well---1?��__ -Distance from foundation___JO_....___.Distance to nearest lot line--,5 f Seepage ---- ------ Number of pits--------/------------Lining material__rbIC -Size: Diameter_-__.3..3..........Depth_._- ---------_-----_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______-_________-----_------_-__----- ❑ Size: Diameter----- --------------------------------Depth---------------------------------- ----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______________-___________________-___. 1n ❑ Distance to nearest lot line-------------------------------------------------•--------------------- ---------------------------------------------------------------------- Remodelingand/or repairing (describe):------- ---------- ----------------------------•------------------------------------------------------------------------------------•------------------- ----------- -------- -•-------------------------------------- ------ .Cly. :.yam-------------------- ---------------------------------------------- -----------------•-------------------------- -------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------•-------------------------------------- I 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. (Signed)-----------------------------#--1 � ��------- - (Owner and/or Contractor) By---------------- � l/, (Ti+le) r� ------------------------------ (Plot plan, showing size ot, location of system in!e1a+ion tow 11uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------------------- ------- ------------- -- -- ---------------------------------------- DATE----- - J61.4-k------------------ REVIEWEDBY---------------------------------------------- ---------- ------- ---------- ------ DATE j- -------------•--------------------- BUILDINGPERMIT ISSUED---------------------------- ---------•------------------- -------------------,--------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-------------- ---------------------------------------------------------------------------- --•----------------------------- --------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ------------------------------------•--------------------------------------------------------------------------------- ------- ------------•------- -------------------------------------------------------------------•----- ------ ----------------------------------------------------------------------------------- -------------------------------%*-------------------- FINAL INSPECTION BY:-------- - --------------- Date------/----Z------ ............................... 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 , Revised 1.57 F.P.CO.