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P'll APPLICATION FOR SANITATION PERMIT Permit No. __.;.7ZI in Duplicate) (Complete t p ) Date Issued - S� ------------------ Applica-l-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. 1 JOB ADDRESS AND LOCATION------------- S _ jQtJ--T S�Q .: = Owner's Name----------=---------------" =rl'_ 2jZ 2, $ -------------------------------- ---------! --------!--- Address------------------------------------- _ Phone _. Contractor's Name,..... -------------------------- ------------------ •-•---------•------- Phone. - --------•- Installation will serve: Residence f [' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ : Number of living units: __L_._-Number of bedrooms --l. Number of baths ---L_. Lot size ------------ � !4O Water Supply: Publiclsystem K'Com munify system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe & Hardpan ❑ Previous Application Made: Yes ❑ No 5L, New Construction: Yes ❑ No l TYPE OF INSTALLATION AND SPECIFICATIONS: s (No sepfic fank'or cesspool permitted if public sewer is available within 200 feet.) E ' Septic Tank: Distance from nearest well-_- ;Distance from foundation--------------------Material--------# _____...__..__________._. No. of compartments-------------•'------- ---Size--------------------------------Liquid.depth-------------------------1 Capacity---------------------- Disposal Field: Distance from nearest well-- %,Q-,Distance from foundation____�d---------Distance to nearest lot line__ ^� Number of lines______________ -------------------Length of each line-------•�---- --------.Width of trench------------Z` T e of filter material_.__ _ _ epth of filter material_________________'___--Total length--------------_5D-- -------- Seepage Pit: Distance to nearest well___________-----------Distance from foundation________--_._______.Distance to nearest lot line----------------- 01 11� Number'of pits-------------------- Lining material------------------------Size: Diameter-------------------------Depth--------------------- �Q Cesspool: Distance from nearest well-----------------Distance from foundation---------- ........Lining materiel_______..____..____.________.___ El Size: Diameter Depth -----------------------Liquid Capacity----------------------------gals. %P Privy: Distance from nearest well-_____ ------------------------------------------Distance from nearest building ❑ Distance to nearest lot line-----------------._ --•-----------------•--------------- Remodeling and/or repairing (describe)_____________________ ------------------- 7------------------------------------------ ------------- ----------------• --------- ----•--•---------•--•-----•--•----------------------•---•--------•------------------••--------------•--------•-------------------- - 1 ' •---------------------- --•------------------•---- "_ _._ --------------------••------_----------- ---- -------------------•-•--------------------------------------------•---------------•--------=•--•---------•------------------------- I hereby certify that l'have-prepared this application and that the work will-6e done in accordance with San Joaquin County ordinances, Sfate I ws, and rules and r gula ions of tl�e San Joaquin Local Health District. U (Signed) ---------(Owner and/or Contractor) . By:--------------•------=------------------• -------------------------------------------------------------•---------- ----------- Tale __ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can-be placed on reverse side). i,. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .- ----- -------------------------------------------------------- DATE------------ REVIEWEDBY-------- "r-----.!--------------------------V$i----:-- - -------------------------------------------------- DATE , BUILDING PERMIT ISSUED••-•--------. t ° , { 1 --•-------------- - ----------- ------- ---------------- -- -------------------- ------------ DATE.---- Alterations and/or.recommendafionsi-----------------{ --- - -- - ---••--------------------•----------- ------------ ------------------------------ -----------------•----------------------------------- ----------------------- ------------------------------- -----------•-------------•------- --- - ----------•------------•---•-----•-•----------•----------•-•--•----------------------- ---------- , ------ --------------------- -------------------------- ------- FINAL INSPECTION BY:. ', Date = a- --- ------=-- --•----------- 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 ; Revised W-2100