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� h .� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ___/�/ 'LX - pllica+ion is hereby made.to the San Joaquin Local Health District for a permit to construct and install the work herein described. 4Ap� . This application is made in compliance with County Ordinance No. 549. p JOB ADDRESS AND O TION._-_�� -�- I6- u( � " = -- ------ ----- Phone_ ' _--- Owners Name_____________ +` °E Address..------ d •--- t-- -- d � '". ..------1---------------------------------------------------------------------------------------------------------------- Contractor`s Name...... + '----- --- ------ -- ------------------------------------------------ Phonely.,_�--&--! 4-Q--- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms ___7—Number of baths _- __ Lot size ------- ------ _____.;2_a-0------------------ Water f__________-__Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table .7,�- ft. Character of.soil to a depth of 3 feet: Sand.❑ -Gravel F]- Sandy Loam ® Clay Loam ❑. Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: .(No septic tank or cesspool permitted if pu jipewer is available within 200 feet.) i Septic Tank: Distance from nearest well-----------------Distance from foundation----A�4---------Material{__e.e No. of compartments------02-----------+---Size---- l'r x��° ---Liquid dep h------6-6 -----------Capacity---'? -0---------- Distance from nearest well_.y}�------Distance from foundation 0.1______-Distance to nearest lot line___:_______ Disposal Field: .17 Number of lines___________-._ _rx_.__ -.-__ ngth of each line------- - -----------.Width of trench-______ _ _ _____________ Type-of filter of filter material------tX.........Total length______116_____________----------------- -------_ I Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line--_-__--__-______ 1 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation-_--_,--------------Lining material__-_--_____-- _--_________-______. _. ❑ �, :.+,.�t�Size:,.Diameter--- wDepth:: :%:,Liquid#Capacity - gals. �� F Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line---- -----------------------------------------------------•---------------------------•-----------•---------------------------- --------- Remodeling and/or repairing (describe):------------------------------------------ ----•------------•----------------•-------•--- ------•--------•-----••---•-----------•--__---------------- ----------------------------------------------------------------------------------------------- _-_.---------------------•-•----•----•-•-----------------------------------------------------•--•--------------- ------------------•--------------------------------------------------------------------------------------------------- -� - ------------------------••------------___------•------•---------------- - ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State-iawsd rules and regulations of the San Joaquin Local Health District. P. "" ,�y' r� , ---------------------------------------------------------(Owner and/or Contractor) (Signed)----------- i "- ------- ----- 11< i B - - e------ ----(Title)...Es � " Y: fy (Plot plan, showing s e f lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------------------------ ------------------------------------------------ DATE--------------------------------•------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ -r ------------------------------------------------------- Alf --f----------------------- --------------------------- Alf gtionssand or recommendations------- ----- ---------------------- ---- - ' ----------�-- - 19 -t :! _ �_'._�' .r' __ ??i_�_4 c '-Y _ -•--_-••------ - n[.---- s.,9 /J':'.'.'l:'' '"'i�_,/ ------------ I --- F -------- ---------- FINAL INSPECTION BY:. ----------- -- 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 i Revised W-2100 11