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APPLICATION FOR SANITATION PERMIT Permit No. ._.. __ V �} 3(Complete in Duplicate) •S Date Issued __--�--_�____. �Application is hereby made to the San IJoaquin 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. G p ^ f JOB ADDRESS AND LOCATION l--' /-- rJ. --rn.----------------------- ' , ,.._. ._r �� y,yy,� ; Owner's Name-----------------------------------------1ll"' c � ----------- --------- - - Phone---- .- - 5 Address---------------------------- c---.�� Contractor's Name----------------------------•-- ee.�A-l------- ----------------- ------ Phone----��_ _� ------- Installation will serve: Residence (n Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: _l-__ Number of bedrooms Number of baths _l---- Lot size ..... f__ _o_.-r_----,- ---__ Water Supply: Public system ❑ Community system ❑ Private [a Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[5- Hardpan ❑ Previous Application Made: Yes ❑ Nolo New Construction: Yes 0 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_sf,-Z.-----Distance from foundation_ _*'__.-- Material__�✓�'�__'_- No. of compartments_---y -------Size__5�_"�/- 3-t__"� _Liquid depth___�=`2-"-_____..Capacity-_XR-e--_---__ Disposal Field: Distance from nearest well=5—_____--------Distance from foundation-J_____ ___--_-Distance to nearest lot line___$_-.---.._.•_{�� 19 {dumber of lines------------�-- __ Length of each line___ _Z Width of trench- -�_ ,T --- 9 Type of filter material--./. ` Depth of filter material---Z .... _.__Total length____1?------------------------ 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 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 ---------------------------------------•-------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):---------------------- --------------------I----------------------------------------------------- -----1-----1*11--,---*-------------------------------- --------------------------•-----------------------------------•------------------------•--------------------------------------------•---•---------------•-------------------------------------------------------------------- ---- ----------------•-------------- ----------------------- -------------------------------------------------------------------------------------------------------------•--------------------------------------------- I hereby crte y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta la.. S, and rules 'a d regulations of the San Joaquin Local Health District. : ------ -----------------------------•------------EWin. Contractor)--------------------------- (Signed)-----------_ r B - � - `'' �"Gt'� Title z�!_.4 Ilz�.F_PJ (Plot plan, showing size of lot, location o system elation to wells, buil, g , etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- - DATE---- -- -- � ---------------- REVIEWED BY------------------------------------------ DATE ------ ---------------------------------------------------- - BUILDINGPERMIT ISSUED--------------------------------------------------------------- ------ DATE-- ,,------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------------------------------------------------------•------------------------------. --------- ----------------------- -------•--------------------------------------------•-------•-•----------------------- ---------------------------;-----------------------------------------------------.----------------------------------------------------- -------• -- -------------------------------------------- --------------- ------------------------------------------------------------------------------------------------•-•------------------------------------------------- -----------•---•-•---•---------------- ---------- ------- ------------ --- -----------------------------------------------------------------------•----------- ------------- ---------------------------------------- 3 5-3FINAL 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 ES-9-2M 10-52 Revised W-2100 -------------J