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r f APPLICATION FOR SANITATION PERMIT - Permit No- ____-. Q -- - (Complete in Duplicate) _ Date Issued -----16 Application i hereby made to 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. 7� JOB ADDRESS AND LOCATION-------- - -------- --A...... .f------------ ' •--------------•-----------1-------------------------------------------------- Owner's Name---------------------- 7?. -�8 --------- Phone - - ---------------------------------------------------------------- Address--------------------------------•-•----•------ ------ ------------- ----------------------•- Contractor's Name-------------------------------- -•------ ---------•--------- -------------•--- ------ Phone---•--------•------------------- - Installation will serve: Residence 50 Apartment House ❑ Commercial .❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/-__ Number of bedrooms -_ .2- Number of baths ________ Lot size _____________________________________________________.______ Water Supply: Public' system ® 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 IR Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ 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-------------.---Distance from foundation-----------------__Material-------------------------------------..-_____.__. ❑ No. of compartments---A---------------------Size-----------------------•--------Liquid depth--------------------------Capacity----------------------- le a Disposal Field: Distance from ne�es,f w�: - �, �DiMance:from foundation____________________Distance to nearest lot line-_____-_____-_- ❑ Number of lines------------------- ---- Length & each line-------------_----------------Width of trench----------------------------- -.--- Type of filter material---------------------------------- tDepth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well----------------------Disfadi gcelfrom foundation_..---__________---.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------------.-------Depth--------------------------------- J* Cesspool: Distance from newest well-- 1 W--_Distance from foundation___ Size: Diameter- l;y 7-1 -------------------Depth......... -------------------------------Liquid Capacity-./,7610-- gals. e L Priv Distance from nearest well-_________________ _ __ Privy: r -#--�---------------------Distance from nearest building-------------------------------------- --. ❑ Distance to nearest lot line------------------------- I------------------ - ---------------------•- ------------------------------- -------------------------------------- Remodeling and/or repairing (describe)-------- --------oe�_S_S__ ... .-----•--- --/....-...... 1_-- ----------------------------------------------------------•----------------------------- 1 --------------------------------------- - ------------------------------------ -- -- - - - - - --------------------------------------------------------------------------------------I.,--------------------------------------------------------------------------------------------------- I hereby certify that°l have prepared this application and"+hat the work will be done ,in accordance with San Joaquin County ordinances, State laws, and rules and regul ions of the San Joaquin Local Health Distric�. (Signed ------------------------------------------ ---------------------(Owner and/or Contractor) f By:-------------------------- `=- ---------------------------------------------------------Title---------------------------------------------------------------- --------- ,. . F ( } (Plot plan, showing size of lot, location of system in relation'wF ells, buildings,,�etc., can be placed on reverse side). .117 -. _ F R F,- RTM NT U5 ONLY // APPLICATION ACCEPTED BY. '.. . DATE 12 ------------------ REVIEWEDBY-----------------------------------------------------------------------------------•---------------------------------------- DATE------------------- '-------------•----------------------- BUILDINGPERMIT ISSUED---------------------------- -----------------------------------------------I-•--------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:__._""_"' " -------------------------------------------^"'----- -) ---------------•----------------------- ------- -------------- J ---- -------------- - -------------------------------------- FINAL INSPECTION Date------------- -- --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D 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 t