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Permit No. . --_-- - �1J� ► � APPLICATION FOR SANITATION PERMIT-,. ��-----'------ - (Complete in Duplicate) Date issued _- - ' 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.�5.49. f G� �I-c �a_ ---------------------- JOB ADDRESS AND LOCATION----------1-=/-----{-------- ----- ----• ---..------- } ------------------------------- Phone------------------------------------ ' Owner's Name------------- �--'---• ►---•-•-�-.I-�-'-�---'�---�----------------- ------------- ------------ ------------------------------------------------------ Address. ------------ -------------------------------------------------------------- Contractor's Name------• -. �. ,-�E] 1 Phone ------------------- Installation will serve: Residence ❑ Apartment HoCommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths ________ Lot size _____________________________ ------------------------------- Water Supply: Public system JLM Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loam El Clay Loam El Clay ElAdobe ❑ Hardpan ❑. Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ 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------------------------------------------------ WNo. of compartments----------- , Size Liquid depth Capacity - e �r -- Disposal Field: Distance from nearest well__-_111-- -Distance from foundation____ d______.__Distance to nearest lot line___ of lines------------- ---- --- -- ---Length of each line_? "t_ d �f�.Wiclth of trench_------- ----------------- Number Type of filter material- I- -----Depth of filter material_; ,--- -----Total length-________19-15-------------------- Type _________________ , st well_._______--________-_Distance from foundation____________________Distance to nearest lot line----------------- Seepage Pit: Distance to neare �., ❑ Number of pits---=------------------Lining material------------------ ----Size: Diameter-----------------------.Depth--------------------------- ' Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------- -- —4) ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------g GV Privy: Distance from nearest well--------------------------------------------------Distance from nearest building---------------_-_------------------------ ❑ Distance to nearest lot line__._-___ -- - e� � - � �:---- --------------- ---------------------- ------ ---------- � j,0-,9nW------- -------- Remodeling and/or repairing (describe):-------- --- ---- A8,11- 1- -------------------------------------------------------------------------- ------------------------------------------------------ ----------------------------------------------------------------•------------------------------------------------ I 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 ru1es and regulations of the San Joaquin Local Health District. ' =------------------------•------------ (Signed)_ `- I " - {Owner and/or Contractor] - --------------------=- r-.. ,. -------------'' - ---------------------•------------------------------ {Titl 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 ACCEPTED BY__________ ___*-- ---r- ----- YL_.DATE------- �------------ R EV I EW ED BY--------------------------------------------------- ------------- ---------- ------------- ------------------------------ DATE--- ---------------------------------------------------- ----- - - ---- DATE BUILDING PERMIT ISSUED------------- Alterations and/or recommendations------------ -----='------ ----------- ----------------- ----------------------------•----- ----------------------------- ------------------- -------------- ---------------------------------------------- - ------•-----------•----------------•----••----------•-•-------------- __ _______________________ -------------------------_-------------- FINALINSPECTION BY-- -------------- - -------------------------- Date--------------� }----- ----------------------------------------- SAN ----- -SAN JOAQUIN LOCAL HEALTH DISTRICT !30 South American Street ' 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi California Manteca, California Tracy, California Stockton, California , ES-9-2M B-51 Revised W-2100