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r 93 7�v �3 APPLICATION FOR SANITATION PERMIT Permit No. . _�'_'Q_ _ (Complete in Duplicate) 7 ./ � Date Issued .......---- V -- --------- 4 �•� ` 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. 549. /Pr qj 33.!"4, � JOB ADDRESS ANCA L CATION /1r---------------------------•• '. f � � Owner's Name- -- ------------- -------."" '------------------------------ - ----------------- Phone---f-....f t f.---- AcIdress---- _- ----------------------------------------------------- 129/ --.. Contractor's Name. - Z-1. .....�" ---------------------------------------------- Phone--�_47 ---------------- Installation --=�a----- Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms _Number of baths __I__ Lot size __ _____ ____..___________________________________ Water Supply: Public system ❑ Community system ❑ Private F Depth to Water Table'iva__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ t Previous Application Made: Yes ❑ No New Construction: Yes ❑ NOX 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-___________________________.______.____-______- I ❑ No. of compartments---------------/------------Size--------------------------------Liquid dept-------------------------Capacity------- ---------- Disposal Field: Distance from nearest well.,(- .....Distance from foundation____/•�7.____-Distance to nearest lot line___:__-__- Number of lines______________ __ ------------Length of each line_______��A_�__ Width of trench._____ _________________ Type of filter material--, ,.- p_�' ___Depth of filter material___.___-/_�_--!._Total length_-_--4d__________________________ Seepage Pit: Distance to nearest w II_._/�,44.......Distance from founclation__- �(_____.Distance to`nearest lot line______. Number of 11 pits-------- ---------Lining material—,__ t--t e-- -7Size: Diameter------ -- .--------Depth_-------- -,- ------------- . Cesspool: Distance from nearest wel --Distance from foundation___ Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-..-------------------------gals. i Privy: Distance from nearest well----------_--------------------------------------Distance from nearest building______________.______-__________._-. ( ❑ Disfanee•to nearest lot line------------------------------------------------ ----------------------------------------------------•----------------------------------- F � • � �r__4 Remod eling and/or repairing (describe):_ . ___ __ _ C _ L ! yQ"r _._.� ---------- -.......-----••--•-•----------•-----•--•--------------------.._...------------------ ----- ----- •---------------------------- Vl ! .-------------------------•-------------------------- ----------------------------------------------------------------------------------------------------------•---•-------------------------••---------------------------------- - -------�� 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 rules and regulations of the San Joaquin Local Health District. (Signed) --------------------------------- --- ----- ---�__ (Oher and/oror Con tracto- - T ` By. ..........................r (Plo+ plan, showing size of lot, location of system in relaVn to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY-------•----------------------- -------------------------------------------------- DATE-----=------------------------------------------------------ . REVIEWEDBY--------------------------------------------- --- ------- ----------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED - ------------------------------------------ DATE----------- ----•--------------------------- € Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------:---------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- --------------------- -----------------------------:-•---•---•----..-----------------•-•-•-------------------------------------------------=--------------------------------•-------------------......_..._..-.----------------------------------- -----.----•------------------------•----------------------------------------------------- ----------------------------------------------------------•------------------------------•------------------------------------------ ---------------------- ------•---------------------------------------•------------------------------------------- -------------------------------------------------------------------------------------------------------•--- FINAL INSPECTION BY:. i!-------- ='+�"-----------------=----- Date----------- -�1 -`3----------------------------------------.. 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 r l E5---9-2M IO-52 Revised W-2100