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Y .... APPLICATION FOR SANITATION PERMIT Permit No.' I v (Complete in Duplicate) Date Issued�_��.-� -� rt Applicatliheby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appmade in compliance with County Ordinance No. 549 1 / LO t ----------------------------------- a � ` 1 JOB ADDRESS ANDC ON------- - ---- - ------ -- ---� --------------- -----------Owner's Name-----------• ------ � { - Phone-_ -_ , Y----- -=---•--- - --------- ----------•-----_ ----•--------------------------------------------•--------------- Address----------------------- -1- 1--- -----__-� Contractor's Name--------- ---------- -- ------------------ Phone. + Installation will serve: Residence &' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1 - Number of bedrooms _ Number of baths _ __: Lot size •___,�_��-- -1-- �`,-------- Water Supply: Public system ❑ Community system ❑ private [k"6epth to Water Table ________ ft. t Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E] Hardpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes ❑ No ❑ I i 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___'5`9-.____Distance from foundation-__t o_ Material-_/ -- --"------------------ Septic - "`°" �j -----Size--p- Liquid depth----_'y-�---------------Ca acct �oo ----------- A No. of compartments------�-------- r--�-�-�-�------�-- qCapacity - ------- Dis osal Field- Distance from nearest weii-_S!�_�-___-_Distance from foundation__�_Q'___-_.___-Distance to nearest lot line.____._____ Q Number of lines-------1------ ---- -�-a---Length of each line---1;--9------------------Width of trench--r�-_�-------------------------- Type of filter material- _� _ Depth of filter material___, -------------- otal length___IAS O---------------------------- est _'________________________ Seepage Pit: Distance to nearest well-____________________Dista nce from foundation--------------------Distance to near est lot line______-.______-_. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well__________ ______Distance from foundation-------------------- material-------_____-__________----_-__-_- ❑ Size: Diameter --:Depth----------------------------------------------------Liquid Capacity---------------------- -----gals. --- t _-_Distance from nearest building Privy: Distance from nearest well-------- �--------- -------------- - •_._ g --------------------- ------------------Distance to nearest lot line----- ----- --------------------------------------------------------------------------- Remodeling and/or repairing (describe)=------------------------- ------------- ------------------------------------___--------- ---------•-----------•-------- -•---••------------------------ ------------------------------------------------ ----------------------------------- ------------------------------------ ----------------------------- ----------------•-------------------------------------------------------------- --------- -- -- -------- ---------------------- - - I hereby certify that I have prepared th is application and that the work will be done in accordance with San Joaquin County ordinances, St laws.4d rulesXaind regulations of the San Joaquin Local Health District. 5i ned ---------------------------------------------------------- (Owner and/or Contractor) ( g } i By=---------------------------------------------- Tale (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 6 1 APPLICATION ACCEPTED BY---- --- - ---- - --------------------------------------- DAT '.f".3'--------------------------------- REVIEWEDBY-------------------------- ------- -- - -- --- ---------`--- ----------------------------------- -------------- DATE----------------------------------••-----------•---------- BUILDINGPERMIT ISSUED----------------------------------------- -------------=----------------------•-------- DATE-----------------------------------------------------••------ Alterations and/or recommendations:--- ------------- ------ --------------•------••-------•---•------------___----------------------------------------- -•----- ----------- ---------I----------------- --------------------=------------------------------------------------------------------------------------------------------------------ 1 ------=------------------------------------------------------------------------------------------------------------------------------- ---------------------------- -- ---------------- ----------------- -------------- ---------------- --------------------- --------------------- ---------------------------------- FINAL INSPECTION BY------ ---------�- `-/ �1,J------------ 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