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G APPLICATION FOR SANITATION PERMIT Permi (Complete in Duplicate) Date Issued A?__ ----��"�` Application is hereby made to ihresan 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-------° 9-- -------- L-------/14/0-!-'/---------',rr - --------------------------------------------------------------------------- Owner's Name--------------—19-, W,0 5--------------------------- --- Phone-----------------------•--------- - -------------------------------------------- -- 1 Address------------------------2-`t Y.0------.... ='y--------- =-------------------------- Contractor's Name • l'9j3ft_i,_.f171------ a ----------Xj -cA--------------------•----------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ® Commercial ® Trailer Court ❑ Motel ❑ Other 10 Number of living units: __Z__ Number of bedrooms ____ Number of baths _3___ Lot size ___ ____JS-a_____________________ Water Supply: Public system . Community system ❑ Private fo Depth to Water Table A0-_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ fAdobe ® Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑�... Uri-a-�-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_________________________________________--.____. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well------._.--------Disiance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----.-_------___-_-.--__-___-__-___ Type of filter material_________________________Depth of filter material----------------------- length-___.____-_-._-___-_-______-_.___---___ t Seepage Pit: Distance to nearest well_____/1fP--------Distance from foundation-----7 ---------Distance to nearest lot line---J __. -14 Number of pats._______------------Lining material_l{ j'%`t{ Size: Diameter----. r -----------.Depth-_-----c �-C-!-.--- __ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material------------.-----------._--_______-- ❑ Size: Diameter--------------------------------------Dept h---------------------------------------------------Liquid Capacity----------------------------gals. 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 +hat the work will be done in accordance with San Joaquin County ordinances, Stat a , and-rvtes and, +ions of +he San Joaquin Local Health District. (Signed) ---•--` t /Jd , (Owner and/or Contractor) 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 USE ONLY APPLICATION ACCEPTED BY ------------ ------------------------ DATE---- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ ; DATE-------------------------------- -------- Altergtions nd/or're mmendation :- ---------------- -------P.-I --- - FINAL INSPECTION BY:------ ---------------- ------ Date---)-0.l--Z--- t "�� ------------------------------------- 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 LS--9----2M 8-51 Revised W-2100