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gt�4�V QJ APPLICATION FOR SANITATION PERMIT Pbrmill- No. (Complete in Duplicate) Date Issued 0 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 AND LOCATION------croa3.... ........ U -------------------- -----------------------1--------- ---- -- Owner's Name-------------------------------------1__�W."I ---------------------------------- Phone-------~"-------- Address hone------r=--------Address------------------------• ------------------- -------- --------------------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------.- Phone------ Contractor's Name- -_--------------- Installation will serve: Residence LK Apartment House E] Commercial [-] Trailer Court [-] Motel E] Other ❑ Number of living units: ---L Number of bedrooms Number of baths LotrSiZe _-.Z -_^_____________________ Water Supply: Public system CK Community system El Private 2f Depth to Water Table _1V_0 ft, Character of soil to a depth of 3 fee+: Sand E] Gravel [] Sandy Loam E] Clay Loam El Clay 11 Adobe E9 Hardpan El Previous Application Made: Yes E] No F New Construction: Yes Lg No Ej TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest Distance from fou ndaf Material----------------------------------11-------------- �. No. of compartments------1Z---------------Size- ----X__ t __----Liquid depth---c�,;R.. ...........Capacity_ffprl;_�!�--- Disposal Field: Distance from nearest well--- Distance Pro'm' foundafion---'T-------------Distance to nearest lot line____ `____ Number ine---- Number of lines--------- -------- ------Length of each line_______41�P-------- ---Width of trench_____S5��....... ................. Type of filter material--- Depthof-filf6e'material--------le?'_f----Total length..........6/�2------------------------- Seepage Pit: Distance to nearest well__10:�--------Di d-nCe r_0) f0_Uii82ir1i5line___ ------D- tance to nearest [of R-47 Number of pits-------4------------Lining ma riall ----Si,et ameter----- Depth-------------------------------- Cesspool: Distance from nearest well-----------------Di nce from.fou J ' ion--------------------Lining material__________________-__________-___-. 1J� ❑ aterial------------------------------------ ElSize, Diameter--------------------------------------Dept -------------------------------------------------.--Liquid Capacity-------------------------•--gals. Privy- Distance from nearest weli-------------------------------------------------Distance from nearest building----------------------------------------- ElDistance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------- ----------------- -------------------------------------------------------------------------------------------------------------------------------- ----------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------- ---------------------_-------- I herebcerfify - a---' - -------------a--p--p---1--i-c----a- ---f-i o-_-_n----a----n----d--------f---h----;-t------f----h---------w------o----r--k------w-----i--1-1-----6----e-------done---i n- accordance----w---it-h----S--a-n---J--o---a----q----u----i n--------County ordinances, State laws, nd rules and r;!ulations of they San Joaquin Local Health District. (Signed)------------I- ----- ---Z --- - -------------------- ----------------------------------- (Owner and/or Contractor--) --------- - - �� -By:----- -- (Plot plan, showing size of . ocafion of system in relelo/ to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- ------------------------------- ---------------------- -- DATE----------- ----- -------------- REVIEWED BY------------ ----------------------------------- -----------------------------------= --------------------------------- - - DATE------------o-- ------ ------------------------------ BUILDINGPERMIT ISSUED------------ --- ------- a----------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:--,--- --------:---------------------------------------------------------------------------------------------------------------- ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------- -------------- ------- -------------------------------------------------------------------------------------------------------- ------------------------------------------------I---------------I------------------------------------------------------ --------------------------------------------------------------------------------------------- -------- - ------------ ----------------------------------------------------------------------- --------- - --------------------------------------------------------------------------------- -------------------------- FINAL INSPECTION BY:-- -------------------------------- Date---------- � � ----- ------------------------ SAN -- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+ree+ 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100