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r APPLICATION FOR SANITATION PERMIT Permit No. _.__.470i._ :.-.t (Complete in Duplicate) it"- " Date Issued _ Application is 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. � JOB ADDRESS AND LO TIO -- 'a`'_ d Owner's Name-------- Phone_.Jam - '________ ---- Address---7-c - I---------------- - ------- vk---------- ................. Contractor's Name--- - -----f t v " -- ----------------------=------------------------- Phone-?`-'_C3 C6 - - - - - - l " ------ ----- Installation will serve: Residence ❑ Apartment House ❑ Commercial 9 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms ________ Number of baths -------- Lot Lot size ----/5-6 Q ,� /�'6 ----------------------------------------- Water --------------------------------Water Supply: Public system g Community system ❑ Private ❑ Depth to Water Tabled_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ Nox 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-------------------- Size--------------------------------Liquid depth--------------------------Capacity--------- - JV # Disposal Field: Distance from nearest well-_____________ __Distance from foundation---�,_ _-�.-__.Distance to nearest lot line-__.J`~ _-_ ----- Number of lines------------ __ Length of each line-----3 A.'........_...Width of trench.._-.2__y Type of filter material---�.t___ _� _.Depth of filter material---._f_ _"_______Total length--------a+ �__________________`__--�� Seepage Pit: Distance to nearest well----------------------Distance frW fou dation-__�._v.1____.Distance to nearest lot line---- -------- I Number of pits------- ------------Lining materialr_ r Size: Diameter-----�_............Depth-----�-Q----------------- .. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_____-------_-----.----.--.--._--_-. ❑�;,. Size: Diameter.------------------------------------Depth----------------------------------------------------Liquid Capacity- --------------------------gals. Pri;,Wr Distance from nearest: well------------ ------------------------------------Distance from nearest building ❑ Ll;sfance to nearest lot line------------•----------------------------------------------------------------------------------------------------- -------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------=---------- ---------------•--------------------------------------------------------------------- •--------- ------------------...--.-•--------•-------------------------------------------------------------------------------- •-------------•-------------- ------------------------------------•------•----------------------------------------------------------------------•---....-.-------------------------------------------------------•------------ - - ----•----- - --------------------------------------------- ---------------- -------------------------------------------------------------•----------------•---------------------- --------- 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. (Signed)----------------------- a + caer and/or,Contractor] f {Title} ---------- By:---------- ----------- (Plot plan, showing size of lot, location of s em in relation to wells, buildings, etc., can be placed on rever'se side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------------------��`;t�=*------------------------- DATE-------------- ��--7 y'__�� REVIEWED BY -------------------------------------`' ---------------------------------- DATE--------------�------------ ------ - ' BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- -- Alterations and/or recommendations:-------------------------------------- -------.------------------------------------------------------------------------------------------------------ -------------------------------•-------------------------------------------------------------------- -----------------------------------------------------------------------------------.--------------------------------- ---------------- --------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------•-•-------------------------------------- ------------------•----------------- •------------------------------------------------------------------------------------------------------------------------------------------------------------- --•-------------- ---------- FINAL INSPECTION BY:------------- ll� .-.__. Date--------------- -7- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California A , Lodi, California Manteca, California Tracy, California 1 E5-9-21A 10-52 Revised W-2100 �'