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. , APPLICATION FOR SANITATION PERMIT Permit No. �.1...a . elf (Complete in Duplicate) Date Issued Applica�ion is hereby made fo the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_______________ __ _" Owner's Name--------- ---------`--•-_-• --------- Phone_ __ 3.1-11-1 1? Address------2zs- 3--- Contractor's Name-------------- -A-6-^------ -- --•----------------------- l -----•--- Phone_?A S/a d A 6 - ------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __02-- Number of bedrooms __o Number of baths _AZ_ Lot size ---- 5 - -- ----- ------ --------- ---------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tablet. Character of soil to a depth of 3 feet: Sand ❑ ,Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes R4—N-o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i S ptic`T nk:r, Distance from nearest well_________________Distance from foundation____.________---__.Material __-________.__-__.-____________- �� •. No. of compartments Size - Liquid depth Capacity ---- Disposal Field: Distance from nearest well_____________ Distance from foundation--------------------Distance to nearest lot line----------------- El Number o{ lines----------------------------------Length of each line------------------------------Width of trench Type of filter material-------------------------Depth of filter material--------------------.-.-Total length------------------------------•----------- ��/ Seepage Pit: Distance to nearest well-_�j�-A___Distance from f undation----,l0___�____.Distance to nearest lot line__ _Q--1-• I- Number of pits----_--�-----------Lining material---....Size: Diameter__--l�sY_�E Depth------o;�_4----------------_ 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 ---------------- g------------------------------- ......... F1 Distance to nearest lot line_______________________________-__.________.___.__ Remodeling and/or repairing (describe)_________________________________ +L ---------•••-----------•-------••---------•-------------------------------------------------------•----- V► Q ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1 hereby certify that I have prepared this application and fhat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulafions of the San Joaquin Local Health District. (Signed)------ 1 R-.. ---------------------------------------------------------------------------------------- (Owner and/or Contractor) By:............ F (Title)-- 2 �- � - -"� {Plot plan, showing size of lot, locatiosystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY�------------- -------------------------------------- --------------- DATE::'-- -- I 1 ------------------------ - ------------------------------------------- REVIEWED BY_- DATE. S ------- BUILDING PERMIT ISSUED__..--- -------------------------------------------- - ------------------- ------------- DATE--------- --- ----------------------- Alterations and/or recommendafions:------------------_--------------- - -----------------------------------------•---------------------- -------•---------•----------------•----------------------•----------------- I -------------------------•---•--------- ------------------------ ------------------------------------•------------------------------- FINAL INSPECTION BY:--------------- -�7J- -------------------------------- Date--------------Q A 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 Revised W-2100