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APPLICATION FOR SANITATION PERMIT Permit No. .�Ve, ~_..Com lete in Du Iicate Date Issued . __plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereed. This application is made in compliance with County Orciinance No. 549. JOB ADDRESS AND LOCATION----- --------------------------------------=----- Owner's Name ,5_-__//1 /i--------- '- ---------------------------------- -_.. Phone------------------------- Address-------�,Q._�c. ' -- -f - •- -------- --- Contractor's Name � �- Phone --- �a Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -.____ Number of bedrooms --� Number of baths __-/_ Lot size ----- - --- ____-_.-- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 2rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe/K' Hardpan ❑ Previous Application Made: Yes ❑ NOX New Construction: Yes. No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-_______________ Distance from foundation---A0_--__---.Mater No. of compartments---------vz------------Sized .�Y_W_4_frS_'L1quid depeh._-__:�_,;t.----------Capacity._____.0 41-_-- Disposal Field: Distance from nearest well------------------ from foundation__A_4P____t_.Distance to nearest lot line---/_ ------- Number o{ lines------ ------ -------------------Length of each line.....3.4__'--------------Width of french...... -c, .J_____________._. Type of filter material__ ._"____Depth of filter material_-_-- --____---Total length--------- A_ ----------------- -- Seepa a Pit: Distance to nearest well----------------------Distance from fou dation___. -r'_.Distanje to nearest lot line--_�S__-/ Number of pits------- ----------Lining material-,3---Rtk�_Size: Diameter__:.-b.......... Depth._.__0R._Q...I----------- Cesspool- __________Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_-.-____-__.________-______-__.______- ' Size: Diameter--------------------------------------De th-----------------_- -_ '""_' Liquid Capacity ------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------. ❑ Distance to nearest lot line- ------------------------------------------------------------------------------------------------------------------------- ------------------ Remodeling and/or .repairing (descril7e): sC- _ ______-- ' ----------------------•-••--------•-----••-------•---------------------------------------------- ------------------------------ 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. I h (Signed)------- ` 1 _._.{ wner and/or Contractor{ By:-------------_-------------- {Title) - (Plot plan, showing size of lot, location of system in tion to wells, buildings, etc., can be placed on reverse side). (/ r FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY-------• ---- ---------------------- ---------------------------------------- DATE-- raj---------------- REVIEWEDBY------------------------------------------------------------------------------------------------ ------------ -------------- DATE---------------------------------- ------------------------ BUILDING PERMIT ISSUED------------------------------------------- DATE-----__-____-_-_____- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------...-•------•-------------------------••-------•- ---------------=-----------•-----------•------•--------•--------------------------•-•--•----------------------------------------------------------------I-----------------------------------------------------------------•--- -------------------------------------------------------------- -------- ------ ------------ -- --------- FINAL INSPECTION BY----- --- --------------------- Date-------,-// - ` _`j� - ------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT I 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 10-52 Revised W-2160 c i� i