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APPLICATION FOR SANITATION PERMIT Permit No (Complete in Duplicate) Date lssuedy_-�___�' Applica4-ion is hereby made to the San Joaquin Local Health District for a permit to constr cf and install th work herein escribe(� This application is made in compliance with County Ordlip any No. 549. JOB ADDRESS A 160 ION--------- ---- - - V_a-lt ---- ---- ----- --------------------- --- - - ---------- -- 11 Owner's Name - P,---------------- ---------- Address--•--- ---- ------------ - ---------- - ------------- -----........... . -------------------- ---------------------- Contractor's Name--------------------- -------d--- --- ---------------- ----------------------------------------------- Phone... Installation will serve: Residence Apartment House [3 Commercial I-] Trailer Court Ej Motel E] Other E] Number of living units: -- ---- Number of bedrooms __4_ Number of baths Lot size ________________________ Water Supply: Public system Community system El Private E] Depth to Water Tableo��ft. Character of soil to a depth of 3 feet. Sand E] Gravel E] Sandy Loam El' Clay Loa TX Clay [] Adobe E] Hardpan Previous Application Made: Yes L] Nox New Construction: Ye No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k- Distance from nearest well_________________Distance from foundation--------------------Material---------------------------------.-.---_---.._.. Ag 0 No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------1 Disposal R Distance from nearest well________________Distance from foundation------------------- Distance to nearest lot line---_____--__--_-- - Number ine----------------- Number of lines---------- ------Length of each line------------------------------Width of trench--------------------------------.-- Type rench--------------------------------_Type of filter material-----___________________Depth of filter material-.-_-______-___----- Total length____--_____-____-___ -------------------- ---Distance f foun a r Seepage ength------------------------------------------ Seepage Pit: Distance to nearest well-,--el�_ -------Distance f i:)Uni4afion--- -.Distance to nearest lot -------------- Number of pits_j----------------Lining material 2,� I ur,--Size: Diarnefer-1--p-------------Deptk__(;��__ Y Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material_..-_--_.--.-______.____________-__-. ❑ aterial------------------------------------- EJ Size: Diameter----------7----------------------------Dept h-----------------------------------------------------Liquid Capacity-------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-__.-._______-______________________._. ❑ Distance uilding------------------------------------------ Distance to nearest lot line----- --------- -- -------- --------------------------- Remod ---------- --- ------------- 01 ing and/ repairin -- - ------ ---------- ------------------------------------------------------------- ----------------- ------------ -------------------------------------- . ........ ...................... ------------------------------------------------------------------------------------..............I------ -------------------------------------------------- - - --- ----- ------------ ----------------- ------------------ ---------------------------------------------------------- -------------__-------------------------------------------------------------------------------- •--- -- I y certify that I have prepared this application and that the work will be done in accordance with San Joaquin County A ordina ce Stat A6 andx, es and regu ions of the San Joaquin Local Health District. --- - --------------------------------------------------- ---------------- - _.�Owner and/or Contractor) ------------------------------------------------------------(Tith (Signe )--- ------ ----- 4- ----- By:.. --- 22 ----------------- ------- -------- 5= (Plot plan, showing size 0. of. location of system in relation to wells, buildings, etc., can bil�?acjad an reverse side). 7 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- --------------------------------------------------- -----1----------- DATE------- �{ T - 7" - -------------------- REVIEWED ATE------- REVIEWED BY----- ------------------------------ --- ------------------------- ----------------------------------------------------------- DATE------ / ..............----------- BUILDINGPERMIT ISSUED--------------- ----------------------------- ------------------------------------------------------ DATE.-----------------•----------------._------------------------ Alferaf'7-and/or recommendations:-_------__- ------- ----- ---- ........ .. __ _ :....... -—- -------------=f-- ----------------------------------------------------------___------------- ------------ --------- -------- ----- ------ ------------- ----------- ----------- --- ----------------------- ------------------- ------------11------------ ----------- ------------------------------------------------------- .... ..... ....... ... ----------�--------- --------- --- ---------------- -------------------------------I------ - --------- .-—---------------------—---------------------—--------- ------------------- ---- ----------------------- -------- -------------------- ---------------- ----I------------------------------. ........ ------------ ---------------------------------------------I-------------------- ------ ------------/.�- ----------- FINALINSPECTION 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 Revised W-2100