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Y .r: ' 4 �� . �{ APPLICATION FOR' SANITATION PERMITS Permit No./�-.- . t (Complete in Duplicate) •---.------ 110 7(s ed Applicafiion is hereby made to the San Joaquin Local Health District foraermit .,Th':s application is made in compliance with County Ordinance No. 549, p to construct and mstaEl4. work hereeii�nd ibed. JOB ADDRESS AND LOCATION__i__-------- O® .� - - _ *.f ----------------------------•--------------"----•- y Owner's Name------- ------------------------------------------- Phone -------------- Address ----- - ---------- ---------------------•-----;-- ----- -------- Contractor's ame---------------- -- ---------------------------------- -- ----- -•---------.. -------------------------------------------------------------------------- Phone will serve: Residence Rii-<partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-E] p Number of livingunits: _ y Number of bedrooms ___�ri ate bar of baths _�____ Lot size ______,��-� _ Wafer Supply: Publics stem Communit system a { ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ V Previous Application Made: Yes ❑ No New Construction: Yes R__M ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted ifpublicsewer is available within 200 feet. Septic Tank: Distance from nearest well_PV_jio:_Distance from founds on______ / n4 _ J fL fQ Material- `----- No, of compartments_--_______" Size__ l __'0f7�_I�AA Liquid depth------� __------Capacity Disposal Field: Dista'rice from nearest well---A"It-,Distance from foundation____-1.i0 Distance to nearest lot line____c�-- "• Number of lines-------------/------------ Length of each line----------- -Q_C-------Width of trench-----_ .-I Type of filter material-____ ____ - --G�-------------- Yp ! �'�.-- _,Depth of filter material------E--�,,-•-------Total length__--------+�-Q-------------- ----- - 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 wellDistance from foundation_____.____________.Lining material Size: Diameter --------------Depth------------ ---------------------------------Liquid Capacity-------------------------.._gals. - Privy: Distance from nearest well--------------------------- ____---_-_._ ___ _____________________Distance from nearest building - �,. Distance io 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, and rules and regulations of the San Joaquin Local Health District. (Signed)_ 's By: -------------------------------------------------------------------(Owner and/or Contractor) -------- ------•--------(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 =.P APPLICATION*ACCEPTED BY------------------ ---,------ ------------------------------------------------------------ DATE-----------�• 1 ---------- REVIEWED BY------------------------------- -----------�- ------- --------- ---------- - ---- DATE----- ---------------------- BUILDING PERMIT ISSU ------------------;-- -------------------------------------- Alterations and/or recommendations: -------------------------- DATE ........................ - ----------- z'` ------4- ---------- � ----- le, 4T , . .__� --- �( - .. 1 . t. 9 �i # ----------------------- ____-_____ 6 = - - - FINAL INSPECTION BY___________ _____ -� r Date- �� --- -------- { 3Is/5q -7h i,5, -a p k wa 3l?r�ad/ i* v5�, tenable-fo e� d a G7 e1,C) �h .I.II .� t,ir� � , SAN JOAQUIN LOCAL HEALTH DISTRICT �s7 �� 130 Sou}h American S}re@} 30D West Oak Street 132 Sycamore Street Stockton, California 814 North."C" S}reet Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 P ,