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6111 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) J Date'•lssued'_-_-�1-��SY� I Application riS 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 Ordin nce No.-549..:.-- _ JOB ADDRESS AND LOCATION _ - -: = _!--" ` ----` Owners Name------------ L_---'-4---- - �� itJ7] C----/ o Phone Address-------------------• •S 3�----- .Contractor's Name------- - w � -- -- ---------------------- Phone - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---6- Number of bedrooms -,'S--- Number of baths -1 Lot size .------ Q- _ S--------------------------- Water Supply: Public system;9, Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes No ❑ New Construction: Yes,,& No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Q (No septic tank or cesspool permitted if public sewer.is available within 200 feet.) Septic Tank: Distance from nearest well-O1�--! Distance from foundation--- Material-- w-j-dA -__-_----. No. of compartments---- -2---------------size------ S-------Liquid depth__ 1I- Capacity-------- ----_-_ Disposal Field: Distance from nearest well- -Distance from foundation--__ ,4_"__-Distance to nearest lot line--- �1 , f�' Number of lines___----:2-�-_�- Length of each line-----V-,P ----- ---.Width of trench-------�4Q_...------------- \ Type of filter material__-____Depth of filter material___----_�Ce----_-_---Total length-- ------------ __-___--_---_ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- 1-1 Number of pits---------------------Lining material----------------------.Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-_-_---_--------------__---_..._---_ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals . Privy: Distance from nearest well-_-----,------------------------------------------Distance from nearest building----_-__-..____---_.--______-------_----. ❑ Distance to nearest lot line------------------------------------------------ ----------------------------------••----•--------•------------------------------------------' V3 Remodelingand/or repairing l -------------------------------- ------------------------------------------------------------------------------------------------- . . ...... --------------------------------------------------•-------••-----------------•-•-----------------------•--••-------------------- ---------------------------------------------------------------------•----------------------------------------•-..........................................------------------------------------------------------------------- -------------------------------------------------------•-----------------------------------------------------.-----------------------------------------------------•--------------------•------------------------------------ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County { ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. (Signed)/k --------- -------- ------'----------------------------------------------------------------------------------(Owner and/or Contractor) a 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 I APPLICATION ACCEPTED SY----------- - - -- ---- DATE-------------___--_-- :- ----- =--------------------- i REVIEWEDBY-------------------------------------------- ------------------------------------------------------------------------------- DATE--------- -----------f-----------------------------•-•---- BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------.-- DATE----------------- ------------------------------------------ Alterations and/or recommendations:------ -------------------------------------------------------------------------------------------------------------------------------------------------------- f -------------------------------------:---------------------------------------------------------------------------------------------------------------------------•---------------------------------------------- --- ------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:----------- __ _ -- __ Date--------- ----.�-- _ _-___- SAN JOAQUIN LOCAL HEALTH DISTRICT . 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 5.51 Revised W-2100