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I APPLICATION FOR SANITATION PERMIT Permit No. (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. 549. JOB ADDRESS AND LOCATION----_-_ -_-�. �_ , � s 11`0 y7-/ Owner's Name-----------1--e- Y 1 5 ' - ---------r ----------- Phone - - - Address---------------- ~- r X _ �� d Y C ------ ------------ Contractor's Name-------- ---------------------------------- __(' Phone Installation will serve: Residence U Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _--4"Number of bedrooms _ Number of baths -Z-- Lot size __-.08k _� �_-y ' -- ----- Water Supply: Public system [:] E]Community system Private.[?r_15_epfh to Water Tabie --------------------- _�� t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loamla Y Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [e_��ew Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s�r is available within 200 feet.) f Septic T n Distance from nearest well___l�_ I Distance fr m founaat' n____ __ Mate1 �� - --- __. rI- --n.�'-'-�--�------- No, of compartments__________ ----._Size_.�Ur 'X ,� I !quid depth Capacity _ Disposa field: Distance from neares well_ __� -.___--_._Disfance from foundation_---l_------_--_.Distance to nearest to Number of iines_____ ------ Length of each fine___ f fr ! -- ---.W+dfih of trench__-- 3 \ Type of filter materially---__-�__--_-------Depth of frlter material__-_/-'�------/T Total length-------1--l------- -- 5eepage Pit; Distance to nearest well__.____----__--_-----Distance from foundation--------------_----_Distance to nearest lot line___________:__-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------Cesspool: Distance from nearest well_----------------Distance from foundation--------.-----------Lining material material____---._--_____-- ____❑ Size: Diameter--------------------------------------Depth------------•--- d __________ ___ -------- -------------------LiquiCapacity --- --gagPrivy: Distance from nearest well-------------------------------------------------DFancevf�om nearest building------------------------------------------ Distance to nearest lot line_____ -------------------------------------------------------------------------------------------------------------------- � I Remodeling and/or repairing (describe)------------------------------------------------------ ------------ 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)------------- q&11t4'x& _-__-----_(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 _____ ------------------------------------ f r •--------------------------------------- DATE---- ---- ---- REVIEWED BY ---- ------- ----- ---------------------------------------------- DATE------ BUILDING PERMIT ISSUED ------------------------- Alterations DATE Alterations and/or recommendations-------- -------------- ........ --------------------------------------------------------------------------------------------------------- -------------------- FINAL INSPECTION BY: ------- ------------------------------------- ----------- Dafie ------ --- ----- ----- SAN JOAQUIN LOCAL HEALTH IST T 130 South American Street 300 West Oak Street 132 Sycamore Sfree} 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100