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�1 APPLICATION FOR SANITATION PERMIT Permit No. C,l..�.. _ .. /t f {Complete in Duplicate) Date Issue ._ ._-5-- •.--_----- Applica+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. JOB ADDRESS AND ATION-------- _ , __ ------__ Owner's Name---•- ----- -- ------------ Phon( ------ Address ----S Sy Address----- SoZ � ,7 --•------ - •------------------------------------------------------------------------------------------------------ ------------------------- Contractor's Name---------• rte_---.__ -- - -_ ___ --------- Phone y�_d G 'Z4 Installation will serve: Residence Pj—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ _-- Number of bedrooms _ '_ Number of baths __l___ Lot size ___ ---------------------- Wa+er Supply: Public system ❑ Community system ❑ Private [E�Depth to Water Table 4sft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: 'Yes E- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 0 epf TQnk: Distance from nearest well_________________Distance from foundation_-.______-__-__---.Material---____--____.________.____________------_-___- No. of compartments-.j--- ------Size--------•---------------•-' Liquid depth---------- ---- ----------Capacity------------------------ Disposal eld: Distance from nearest well--,rd-_--._Distance from foundation___./4._____-.Distance to nearest lot line--_S_______ Number of lines-----------/- ------------------Length of each line------ ?-5 -----------Width of trench------;?y------------------- of filter material__S P_ _____Depth of filter material----J!F---._-_-_--Total length____________ --------------------- TypeV` Seepage t: Distance to nearest well____7..�_..________Distance from foundation.__-.Z'o.......Distance to nearest lot line--__s___._._. Number of pits------,1-----------=Lining material CC'__ Size: Diameter-.----AV-------Depth-_- -------------------- Cesspool: ------------------ Cesspool: Distance from nearest well-------`---.-----Distance from foundation--------------------Lining material—__________________________-_-___ ❑ Size: Diameter------ -----------------'_._ _.__.__Depth------------ ---------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well____ >_.... x_____------------------------------Distance from nearest building------------------------------------------ El 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 o the San Joaquin Local Health District. ,�O f -------------------------------------------------- (O r a /or Contractor) BY: �1 A •---` --------------------------------------------------- - {Tiitle)------------ -- -----------------------------------' �-� (Plot plan, showing size of lot, location o ystem in relation to wells, buildings, etc., can be placed on reverse side]. FOR1 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- --------- -------- w-- u' ----------------- DATE----- `5 •---------------------- REVIEWEDBY--------------------------------- - ------------------ ----------------------------------------- ------------------ DATE--------------------------------I BUILDING PERMIT ISSUED------------------------------------------------------------------------I----------------------------- DATE------------------- ----------- ------------------------- Aiterations and/or recommendations:---------------------------------------------------------------------------------------------------------------------------------------------- ---------- -------------•-------------------••-•------------•-----------------------------------------------------------•--------•-----•--------------•-----.-•--•---------------------------------------------------- ............ ----------------------------------••--• ----------••-----------••-•---------------.----•-------•---.-.----•----_--.------------•-----------------------------------------------------•.--•-------------------------•-•------- 1-------- FINAL INSPECTION BY:-------.---— ---- Date...-------------�� .__s- k SAN JOAQUIN LOCAL HEALTH DISTRICT x 130 South American Street 300 West Oak Street 132 Sycamore Sfreef $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California /S-9-2M ; Revised W-2100