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APPLICATION FOR SANITATION PERMIT Permit No (Complete in Duplicate) rl g� p Date Issued .---/ ---.- Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her described. This application is made in compliance with County Ordinance No. 549. / l �- 1� ---------------•--------------------------------------------------- JOB ADDRESS AND LOCATION--------- '--_ __( Q.--.---_ - _-• -•- -- -- ' -- ------------ ----- Phone------------------------------------ ------------------------------------Name ----- ----- -----•--------------0--- --/-------------------------------------- Address---------- GI �----- -�'�/'----- -vr--'------------------•--------------------------- Contractor's •.. {`'{�IVS------------------•------------------------------------------------ Phone-A4;-__'_,__ - Installation will serve: Residence 0 Apartment House ❑ Commercial I& Trailer Court ❑ Motel ❑ Other ❑ 0 Number of living units: -------- Number of bedrooms -------- Number of baths -1----- Lot size ---- -A---kU_??.__---_-__------------------ Water Supply: Public system IK Community system ❑ Private ❑ Depth to Water Table... - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3, Hardpan ❑ Previous Application Made: Yes ❑ No [X_ New Construction: Yes Jq No ❑ 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---Ab_? '_Distance from foundation---/L}----------Material--- ------------- r No. of compartments-------�---------------Size 4_7i ---Liquid deoll--------6'-a--------- -Capacity----- rn n Disposal Field: Distance from nearest well_- AbtV Distance from foundation---_- Y ....... to nearest lot line--- ^-g___-- LV Number of lines,------------- �.� ------------Length of each line - ------------Width of trench---------1- ------------------- Type of filter mateal._4�____-5Xr__Depth of filter material--_----/ --__-- _---Total length----- ---------------------------- n Seepage Pit: Distance to nearest well-_A4 M-� --Distance from found`ation,_.__ V_0---....Distance to nearest lot line----/--__.-----. Number of pits------- -------------Lining material-- Cesspool: size: Diameter------�=?y---.---Depth-----. ?-`',',------------- IV* 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------------------------------ --_.-. ❑ Distance to nearest lot line---------------------- ------------------------------------------- ---------------------------------------------------------------------- Nei 6 Remodeling and/or repairing (describe)----------------------------------------------------•----.......-------------------------------- --------•------•----------------•----------------------- 3 --------------------------•-----------•---------------------------------------------------------•----------•---•--------------------------------------=-- ` ---- ------- ----------•---------- ---------------------------------------------------------------------- -----•---------------------------•---------------------- -------------•----------------------- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stws, and rules and regulations of the San, Joaquin Local Health District. ' ____(Owner and/or Contractor) (Signed)--- .... .. .1�9- / " BY:.. y- i.. !, - a.Z= (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---------•-------------- Z--------------------------------------------------- DATE REVIEWED BY---------------- -------------- ---------- - --- - DATE ------ - r DATE � BUILDING PERMIT ISSUED----------------- ------- ------.-o -- -- ._...__.-....Alterations and/orrecommendations:- ------ �� ---- - ----------------------------------------------•---•----- -- — -------------------------------- —.. "a _ .lf ---------- ------- ---------------------------------- --- - -- - ---------:.- ��-------------- --- : FINAL INSPECTION BY----- -------- ------------------------------- Date----- --/t --5-- 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-2180