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/r 61� APPLICATION FOR SANITATION PERMIT Permit No. �✓ (Complete in Duplicate) Date Issued 31 ed. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr b This application is made in compliance with County Ordinance No. 549. f� -- --- yA -------------------------------I--------------•---------------------- JOB ADDRESS A OCATION-- ---- ----`a--�-- I-�- �/ �l ------------------------- Phone �o� / i Owner's Name---------- -- ---- ----- - ---------------- -- - -- --- ----- -- ---------------------------------- Iz Address----------- -- ---- -----+-- ------- -- ---- --------------- --------------------- ------------------•----------------------•----...-•-----"-----------------•----------------------•- Contractor's Name.... ---------------------- Phone--------------------------------•-- --------------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mrotgl Elther, ❑ Number g of livin units: -0Z umber of bedrooms ___� Number of baths _"Z- Lot size ___6 c� -x_I --------------------------- Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam El Clay El Adobe 2e/Hardpan ❑� Previous Application Made: Yes ❑ No dNew Construction: Yes Rr'No ❑ Q TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) j Septic 'perk. Distance from nearest wel_ _ Dista fro fou a ion___"_____�l-----.Mater! I_ --------- - ---- 'Z �, No. of compartments------- -----------------S ize_ x-�X-- ------Liquid depl!tl}�--------- ---------Capacity------ !/_ _- Dispos ,'Field: Distance from nearest we ____ __________ !stance fro foundatiion_"----�-L-----Distance to nearest lo,, Ij ��----------- ,'Field: Distance Number of lines_______ WA" L th of ach line--------------- .1t--_--Width of trench-------_��_f-------------- i --------Total length-------------I -----------_ Type of filter ma ria__ -- - -- "--______ e of filter matenal_____..r Seepage Pit: Distance to near st well------ -----.-------Distance from foundation-------_------------Distance to nearest lot line______________-__ ❑ ---Lining material-----------------------Size: Diameter.----------------------Depth-------------------- Number of pits___________________ ""'"-"------ Cesspool: Distance from nearest well_______-_-_-_-"_Distance from foundation--___"_-________---Lining material"--___-__"___--_____"_____________ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------- ----gals. Privy: Distance from nearest we41_"_"__"_"---________----------------------------Distance from nearest building_--_________-------_..-.--------------- ❑ Distance to nearest lot line--------------------------------------------------------- --------------- ---------------------•--------•---------------------- 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, an-j rules and regulations of the San Joaquin Local Health District. " r�•.,,_l.�.:»-- --------------------------------- -- --------------------- ------------- Ownerand/or Contractor) {Signed:}------- ----...--{- - -- --- 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--- -------------------------- ------------------------------------------------------------------ DATE---- ----------------------------------------------- REVIEWED BY-------------------------------------- ------------ ------------------------------------------------------------------- DATE-----"I?- BUILDING PERMIT ISSUED---------- _ DATE_.__.-_.___ Alterations and/or recommendations:-------- ------------- -- ------------------------------------- ------------------ --------------- ------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------ 1 ----------------------------------iX --- ------ ---------------------- ------------------------- �f' FINAL INSPECTION BY:--------J 1-----•r-r- ------------------------------------- Date----- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 13:0 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfree+ Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100