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ArPLICATION FOR SANITATION PERMIT Permit No. „5-�'d. __. (Complete in Duplicate) .1 -- Date Issued Applica{ion 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,LOCATION----------- oZ0---5'------T-----'P��r%-Q________ AOddress.-Na .._ - Phone------------------ ----------------------------- --- ' T _....--- ----------------------------••---------------------------- ----------------------------------------------- Contractor s -Name _____,...___rlC _ -�- f Phone-------•---------••---------•------ Installation will.�serve: Residence �tment House ❑ Comnlercial ❑ Trailer Court ❑ Motel ❑ Other ❑ a y r ! Number ,of living units: _Number of bedrooms _ ` YNumber of baths t size ------_��_�___�., C� ------------------ Water. Supply: jPublic sysfem 5JO- mmunity system ❑ Private E] Depth to Water Table -------- ff. I Yui„[."_y11,�'�. w-'rr'1.�r+�.�.-_ ._ Character of *oil to a depth of -3 feet: Sand ❑ Gravel ❑ Sandy Loam X Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Appllcetion Made: Yes E]' No';R- New Construction: Yes 9 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ,.�. (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septic Tank: Distance from nearest well&,t�y_�_�Distance fro oundation__.Material _ V ---- �, No`. of compartments.=:: __.-�"'-----Size--!'� -- Liquid depth -------- Z,�.----------Capacity--- Disfosal Field: j - 'Disfance-fs'om jontaeest .well.i!� Distance from foundation.___—f-, -Distance to nearest lot r J Number,of. lines_ --------- _.---- --------------Length of each ' line ------------------------------Width of trench Type of filter material -------------------------Depth of fitter material ----------------------- Total ------------------------ ----------- length----------------:------ ----------- ------ Seepage Pit: Distance to.,nea.r.;k_w.ell---------------------- Distance from 'foundation -------------- ______Distance to nearest lot line _____--____-_____ 1 . ,.� ❑ Humber of pits----------t-_--'-`---Lining "maferi6l ::-"`--"-------Size Diameter----------------------- Depth---------------------- ,Jn # �- f Cesspool: Distance from nearest well ( Disf`adce froi'n foundation Lining matperial------------------------- [71__ .--gals -- - _ �T - ' l `ES.ize: DianieteF. _ _ - - I Dept -h--:!7 -- ��... Li uid-Ca acit - = = = -'.--_ = -- Privy: Distance from nearest well---------------------------t-__-----------------Distance from nearesr building .--------------- ------------------------ � , ❑ Distance to nearest lot'line- ---------------------------------------------•------,------------ Remodeling and/or repairing fclescribej:_,___.-_.____--- ) ----------•----------------•• ---------------------•-- # _ ..- --------------------------------- ----------•------------ _______________________________________________________________«___--___....__.______-___.__..._________--_________._______-_.____ f__ ----------- ___________._____.._____._. ____._.___.-____.-_-_-_ 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) ------------- ------------ --------------------------------------------•-------------(Owner and/or Contractor) BY= ----------------- I --------- (Title)-- - -- ----- - --•-•- ------------------------------------ (Plot plan, showing size of t, location of system in relation to wells, buildings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLYR APPLICATION ACCEPTED BY --------------------- �•..- ------------ DATE ----------�-_:- REVIEWED BY -----=------" --------- "'� ��------ T--------------------------------•--------------------------- DATE BUILDING PERMIT ISSUED-------------------------------------- -------------•-- -•------- •------------------------------------------------------- DATE.--- ------------------------- -- - Alterations and/or recommendations --------------------------------------------- --------------------------------- ----------------------- F1NAL'INSPECTION BY: --w--------- ----- -------------- Date ------------------ `- 2 S — 37-s— -- ----------------- ••--------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised W-2100