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APPLICATION 1=0R SANITATION PERMIT Permit . ----,1 S_ -. (Complete in Duplicate) W_ _ff� Date Issued __.-_ Applicaa-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. JOBADDRESS AND LOCAION---------------------------------------------------------------- ---------------------------------------------------•-----------------------------;.------------ Owner's Name----------- ' �--c-•--r-"-- -------• ------------------------------------------ - ------------------------ Phone------- -------------------------- Address4/-------•------- / -- Contractor's Name______Ol_�_ �I=r- - -----•-•---•-------------------------------------------- --------------------------------------------------------------- Phone...-------•---- -------•---------- Installation will serve: Residence J' Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.I>'____ Number of bedrooms __2--- Number of baths __1----- Lot size --- _�_L� Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoNf New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ( o septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: 1 Distance from nearest well_________________Distance from foundation--------------------Material______-_-______.___________________.__________- Ef No. of compartments----------------- -------Size--------------------------------Liquid depth_------------------------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line___--__________-_ �] r Number'of lines-----------------------------------Length of each line-----------------------------.Width of trench-,---------_----------------------- CX��t Type of filter material------------____---------Depth of filter aten ___._.______-----.__.__Total length-------.--_____________________________-- 1 1 Seepage Pit: Distance to nearest well_J_[�_Q- -___-__Distant rom foun io __________________Distanr�e to nearest lot line___ ___.__ Number of pits----f----------------Lining materia 2__I-___Z_1fi0_i`ize: Cesspool: Distance from nearest well-----------------Distan from foundati _--_---_.Lining material-_________________-____________.___. ❑ Size: Diameter----- ------------------------------Depth-------- ------- ------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------._._-Distance from nearest building--------------------.__-----_---__-__--- ❑ Distance to nearest lot line-------- -----------------------------------------•------------------ Remodeling and/or repairing (describe): ''~- r� - '�`.`�' ---------------------------------------•------------------------------------------------------ .----------------------------•.. ------- --------....--------------------------------- ----------------------------------------------------------------- --------------------------------------•---------------------------------------------••------------•-----------------------•-----•-----------•------------------------ 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 rule and regulations of the San Joaquin Local Health District. (Signed)-- /.r.-t ... --- --- ---- -- --- ---------------- --------- •--------------------------- 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-------- - ----------- ----------------------------------- REVIEWED BY------------- -------------------- DATE---------- BUILDING PERMIT ISSUED------------- - -- - -- DATE v 4 S , ---------------- Alterations and/or recommendations------------------------ ------------------------------•--• ------------------•-----------••-----.._...---------------- -- -----------------------------------------•---------------------------------------------------------------------------------------------------------:------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------- --------------- •---•--------- - FINAL INSPECTION 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