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r ` APPLICATION FOR SANITATION PERMIT Permit No. __. ------______ (Complete in Duplicate) Date Issued __3 �'s� 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. Z9 16 A JOB ADDRESS AND LOCATIO Owner's Name-------------- G/.--_____ Phone_ _ - -Address----------.•��- wr. - -- i -- --------------------------------------- Contractor's Name------------------------------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/____ Number of bedrooms _'�-- Number of baths __. ___ Lot size -----f�------------------------------------------ Water Supply: Public system ❑ Community system.❑ Private ® D.epth.to Wafer-Table /4. ft. 1101 I-v Character of sail fo a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam V_Clay El Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No 5. New Construction: Yes IS No ❑ w �'�` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �e Septic Tank: Distance from nearest well--JA-.._____Distance from foun ation----14-1-.--_..-Mater�l____t. _ � Liquid depth------ ----- ------ - Capacity----- ' 6 ® No. of compartments_.____2.�-__-._-.____Size__�,e� � -------- �--- 6. Disposal Field: . Distance from nearest well _ __-_-Distance from found atior�-----14-0--- 4stance to nearest lot lipp----- N ; [� Number of lines____3-_____--__-- Length of each Iine�� ,?.Width of trench_._ .__. -----________. Type of filter material-- o -Depth of filter material--- - --- - -------Total length------l_��._-___..___________--__._ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------..Distance to nearest lot line_.--___.____-____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Dept h-_-----.------------------------- Cesspool: Distance from nearest well________________Distance from foundation-------------------kining material-------.----------------------------- Size: Diameter-------------------- ----------------Depth -- -----------------------------------=--- ---------Liquid Capacity------------------------ gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------.------- e ❑ Distance to nearest lot line------------------------------------------------ Remodelingand/or repairing {describe):------------------------------------ -----------•---------------------------------------------- -------------------------------------------------------- I ------------------------------------•------------- ._..----------------------------------------------------------------------------••••--------------------------------------------- ------- ---------------- - ------------------- -------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- -1 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. - --(Owns(Owner ContraTctor) a (Signed)---------- -------- --------------------- By: ---------- -- Title-------------------------------------------=------------------- ! (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ` FOR DEPARTMENT SE ONLY I. APPLICATION ACCEPTED BY--- .,PDATE 1 �� -5`� ------------------ REVIEWEDBY-------------------------- --------- -------------------- DATE BUILDING PERMIT ISSUED ------ DATE------------------------------------------------------------ iAlterations and/or recommendations--------------------------------------------------------------------------------------------------------------------- --------------------------------------•- i ---------------•.-------------------------------------•-•--•-------------- -----------------------------------------•-------------•-----------------------...--------------------------•-------------------------------- r • fC --------------•-------------------------------�- �----- ---------------------- ------------------ T ------------------FINAL INSPECTION BY:..--- Date------ ------------------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Nor+h "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 y ES-9-2M E0-52 Revised W-2100