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A_ �j ,, TION FOR SANITATION PERMIT Permit No. _____ IM {{ y �` (Complete in Duplicate) rl �l etfk ' 1 !/ 1Date Issued - /_7 _,jApplicatlon is he 7 he n Local Health District for a permit to construct and install the wor This application is made in compliance with County-Ordinance No. 549. k hereirrdesc'ri,bed. JOB ADDRESS AND LOCATION--------- Owner's ------Owner s Name---- -- ' Phone --------------------- Address---- a f - x/ tl Contractor's Name---m-k✓l✓ Y"' --------------------------------- - - -------------------------------------------- ---------------------- Installation will serve: Residence V Apartment House ElCommercial E] Trailer- Court ❑ Motel Other ❑ J , Number of living units: -1____ Number of bedrooms _ __ Number of baths j---- Lot size ___S_ _ _ f c7 Water Supply: Public system )4 Community system ❑ Private ❑ Depth to Water Table -------- ff..r Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam' Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:, (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .SepticTank: - Distance from near.e t weI[; _Distance from foundation____9__�--__`.-Material__`_____'. -�: ____________ ___`---- }`j" y No, of compartments_________ ,Z-____'___Siz _ r" - ----Liquid depth_l_'_�. 3---------Capacity__r4 - e , Dispgsal Field: Distance from nearest well ! --Dist nce from�oundation__�_ Y_'___-_-_Disfance to noarest Number of lines----------- --- ------- --- Length of each"'Jirte---/__'�__4-- -"--•--.-.Width of trench----� Type of filter mate ria l__-_ _---,Depth of filter material__- __ _L0 ' ---Total length--------- 0-__----_-_'----- Seepage Pit: Distance to nearest well_____-----------------Distance from foundation--------------------Distance to nearest lot linel ❑ Number of pits------------ ----------Lining material---------_-------------Size: Diameter------------------------Depth________---____------ ------ Cesspool: Distance from nearest well________________Distance from foundafior,__-_;`-._-'--------.Lining material___-____-___-_________.-___________ ❑ Size: Diameter------ ------------- ------------De th----------------------------- -------- Liquid Capacity -----gals- Privy: -Distrance from nearest weH _ _________________________________-__--__Distance from nearest building ❑ Distance to nearest lot line_-------------------- --- ---- ------ ------- ------- ill ,a Remod•lin and or re airin descrrbe :_. __ • � _� ~--- --U- -S = -----•-----------------------------------------= --------- --------------------------------- - Tr;: _ ------------ ----- - '-" •---- - == - ----- - - `-- ------ -- --•---- I hereby certify that I have prepared this_application-and_Wif the work will be done in accordance with San Joaquin County ordinances, State laws,_and_r les and regulaaians of the San Joaquin Local Health District. (Signed'X-6 ------ ------- -Y- � w ------------------------------------ - By:-------------------------------------- ------------------------------------------------ O ner a d/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._ APPLICATION ACCEPTED BY__ _ DATE ------------------------•------------------- REVIEWED BY------------------------------------- ------ -��. -- - 1 -- --- - ---------------------------- DATE------- - -- --- -- --- -------- =- BUILDING PERMIT ISSUED ----t�--- ----------- ------------------ ------------------------------------------ DATE ---------------------------------- aerations and/or recommendations___________--------- --- ---------------------------------- `�---14< ------tea I; ---- --=---------------------------------------- ---------- - � -- 5a► S Sha Saw ,� v �� FINAL INSPECTION BY:---------------_- Date------ �------- - ---- _ � - --------------------- , 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 FE ES-9-2M 8-51 Revised W-2100