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ti APPLICATION FOR SANITATION PERMIT Permit No. ._4�.��-d (Complete in Duplicate) Date•issued Applica*ion 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. } 3 G ------ JOB ADDRESS AND LOCATION_______----•- I -�-•------�%yf--��"Q ----- D :.1 ------- Phone-------------------------------- ----------------Name------ __ _� --------------------------- Owner's - ---------------- ---------------- Address-----•-- ----------= ht�c'_V- ----- ---------------•-----------•-------------------------------•--•---------------------------- ----------- _ Contractor's Name n` ----- -- -------- ----------------------------------------- __- Phone_^__ --. �� Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ 'Motel ❑ Other ❑ Lot size 1 d ----------- Number of living units: __ -____ Number of bedrooms •_L_-. Number of baths __� '� Q JJF Water Supply: Public'system ® Community system C14 f Private ❑ Depth to Water Table ___ -- ft. Character of soil to a depth of 3 feet: =Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam!I] Clay ❑ Adobe� Hardpan [I Previous Application Made: Yes ❑ No 14 New Construction: Yes [k No ❑ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200feet.)' , Septic.Tank: Distance from nearest well-----�-------Distance from foundatio ------------ - -- ---Liquid depth----- --------------- Ca acit d No' of compartments----------,�.---- Size__S�__x_ _ P y.-•- Disposal Field: Distance from nearest well___'-------Distance from foundation_____--_ - Distance to nearest lot line�._.__74._._-__ _---__Len th of each line___-__-._ . Width of trench _ --------------------- Number of lines___- 1-- --r----= g -4 -- ----- - --•-.Total length QST Type or filter material___-��__-P¢q Depth of»filter material____-_� S_.�-- .�. Seepage Pit: Distance to nearest welt__________ _-----Distance from foundation__.. Q_.__..___.D�staice to nearest lot line-1__'�_.----- Number of pits- ----I- ---- - - -- - ze: Diameter----33--- -------- Depth �''�_ w _Lining materia{___�_G - Cessp ol: Distance from nearest wel!_________________Distance from foundat ion---_._____.....�__-..Lining material-------------------------------------- Depth - ---r----Liquid Capacity----------------------------gals. Size: Diameter------- ------------------ ------------_ ❑I Distance from nearest well -----------------------------------------fi. _T.-Distance from nnearesf building.-t--..------------------.-------------- Privy: Distance to neare st lot line----------------- ------------------------------------- ------------- - El --------------------- Remodeling and/or repairing (describe):--------- ----•----------------------------------------------------------------------- - -----•-----•------••----------------- t ---------fi-------------------------------------------- -------------- --------------------------------------•------- -------------•-------------------•---------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l ordinances, State laws, and rules and regulations.of the San Joaquin Local Health District'. �' ' Owner and or Contractor ,.�,.,,• ----------------- ) - -- - r (Signed)...- �-•� ------ ---- l s -�t (Tit e) — :. (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 ACCEPTI D BYii -------------- DATE -------------------- ------------ REVIEWED BY------------------------------- DATE tea--=- = = BUILDING PERMIT ISSUED-------------- -- _ DATET'__: � Alterations and/or recommendations:_.-_��I------------------------------ -------------------------------------------- - ---------------------------------.....-•-------------._..-..----- ------------•--•------- -------•------ --•----•--�'�-'- l ------------------------------------------------------------- I --•-----------••-----------•-------------- ---------------------------- ------------ _____________________________ ___________________________________ ----------- - F1NAL INSPECTION BY:__ �-,�----------------- -------�- --- -----• Date---- ------------- •-------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 4914 North "C" Stas+- " 130 South American Street l 300 West Oak Street 132 Sycamore Street Stock}on, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100 _