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1� ,�`� APPLICATION FOR SANITATION PERMIT Permit No. .y- '� � (Complete in Duplicate) Date Issued _y4-f/-S-). 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 C}}ounty�Ordinance No. 549. JOB ADDRESS A LOCATION---'E -L/ _Q- l--- "� ------ Owner's Name. � - -------------- ------ Phone------------ f f Address ' ------ -------------------------------------•-------------------------------- Contractor's Name---- ------- ------------ ----------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote) ❑ O er P Number of living units: ___�_ umber of bedrooms ---Z Number of baths ___L Lot size __:L15---;!S_440_______________________ Wafer Supply: Public system Community system '❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ZGravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe �ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yeso ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if, ublic sewer is available within 200 feet.) r Se tic ank: Distance from nearest well _ ____-___ ista ce fr fou ion____,�_f�________.Mate ia __________ _ p 4-' No. of compartments____._ ________SizeC _x ___Liquid dept_____ Capacity_____ Il �V ----- _ ----- c-�_ Disposal field: Distance from nearest well____-__Distance from foundn____ __'____-�istance to nearest lot i gr__S __.___. Number of lines____________ # ____ Length of each line__ _�_=_ � " Width of trench-____ _ __ g t------------- Type of filter materi ± _ (t4Depth of filter material_________ _ ___Tota] length--_,_-___ _M_ ________________ Seepage 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___________-_____-________-________-. ❑ 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)------------------------------------------------------------------------------------ ---------------------------------------------------.----------------- -----------------------------------------------------------------------------------------------------------------------------------------•-•-•--------------------------•--------••------•-------•-------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------•------------------------•--------------- T 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)---- ------------------ ------- /_` -----____-- --------------------(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 1 APPLICATION ACCEPTED BY ----- --------------------------------------------- ---------------------- ----- DATE- REVIEWEDBY----------------------------- ---- ---- - ------------------- ------------------------------------------ DATE------ BUILDING PERMIT ISSUED-----------------------------------------------------------•------------------------------------------ DATE-------------____- - - --- ---------------------- ._ Alterations and/or recommendations-------------------------------------------------------------------------------- --- ---------------------------...--- --•--------------------------------- ' ------ - - - - --- - - - Al � .. ---------------------------------------------------------•--------- --- ------ --------------0F-------------------------------------------------- ------------------------------------------------ _ -- FINAL INSPECTION BY:-- = - _- Date --------- -- -------------�-r---------------------------------- 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 8-51 Revised W-2100