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APPLICATION FOR SANITATION PERMIT' Permit No. O___ _...._ ji (Complete in Duplicate) Date Issued _____ __!._y _A3 Application is herebythe San Joaquin Local Health District for a permit to construct and install the work herein described. This application is mampliance with County Ordinance No. 549. k - JOB ADDRESS AND L CAT] ..._______________ �L._ -------------:.-.__----------------------s---- ------------ Phone--------------------------------•--- Owner's Name--------- •--- - - -- - - •--•----�`." ---•- x Address.. • --_--- = _ r L� --• ---- Contractor's Name- /`2��---------•------ Phone----- -- -- . - �� . Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- umber umber of bedrooms•.'_-"'Number of-baths _I___ Lot size ___-Taw --X- -��0------------------ Water Supply: Public system Community syst"m ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe Hardpan [I (,A Previous Application Made: Yes No New Construction: Yes 310 [-] ❑ .v� TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No se c tank or cesspool permitted if public se is available within 200 feet.) a O `/ ''��ff , istance,from-foundation_ _d___--.____.Material__ Septic T Distance from nearest weIIJ_l��Y�-__-_yLJi � Z_ -Acr- No. of com artments__ _ ----- --- • r -- Liquid depth --- -- �---------Ca acc p � Ize /� p y---- Disposal F' Distance from nearest wehd&_W Distance from foundation_I_-______.`__. istance to nearest lot I ne_-/-d_______. Number of lines----- -- Length of-each lin e____6--d.!-------- __°...Width of french___________._-_4_ __.___.. ❑ Type of filter materials Depth-of filter '-Total length__-_. " _.__ __ • Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-_________-_-____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- i IA Cesspool: Distance from nearest well-----------------Disfance from foundation----------------F__.Lining material------------------------------.-____. 1 ❑ Size: Diameter._. ;`-------------------------=---Depth---------.---------.------- ------------------==. Liquid,Capacity----------------------------"gals..,,.. .... Privy: Distance from nearest well------------------F-------.----------- ----------Distance from nearest building--- Distance to nearest-:lot line--------- ----- -------------------------- -------•--- ---- - ----------------------------.. - ----------- ❑ w Remodeling.and/or repairing (describi ]:----------- ^- ------4 -••---•-- { �' = -- - ------- - __R -- et-' -'-4------------------------------------------------------------------ -------------------------------- ---------------------—--------------------------------------- I herebycertifythat I have re tired this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and rbgulations of The San Joaquin_ U 1 Health District- (Signed) u ` �._�_ __� nor an�j�or Contractor (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be paced on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ -- ---------------------------•-------- DATE__ - REVIEWEDBY----------------------------- --�- ------------------------------ --------------------------------------------. DATE--- �-----------------------------••-•------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------=--RrA-.-----•---------------------------------------- Alterations and/or recommendations:-------------------- -------------------------------------------------------- U'---------------------------------------------- ---------- ----- t----------------------------------------------------------- ------------- ------- �Q �b - =----- -------------------------------------------------------•-----------------------------------------------------------------------_------------ ------------ ---------------------�- /--------------------------------- 7 FINAL INSPECTION BY:--------- -- - -• =-------------------------- Date. `, / ------------------------- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I ( ES--9-2M 10-52 Revised W-2100