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Il APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ScANNE® VVV ate Issued Y2-3�,�=-y �!V Application is hereby made to the San Joaquin Local Health District for a permit to const uct and in II the w�ork herei�n deys�i.bed. This application is made in compliance with County Ordinance No. 549. O JOB ADDRESS AND s LOCATION__-- - ---------6d .---7 Owner's Name________ --- ---------------------- --------- -------------------------------- Address P ------ 9 - Contractor's Name------- ----- __.-.._-- .-_ - -- _._--- --- - - -------- ---- Phone-- ----------------- - - - - -------------- Installation will serve: Residence'K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J---- Number of bedrooms ---I--- Number of baths __j_._ Lot size .__> ---x j--e-j - - -- - --------- Wafer Supply: Public system E] Community system ElPrivate 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 ❑ Nom 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_-�_jP-_q SDistance from �+ rq . Qfor-u-nda._tt-ionq.__._4 ?_. #M-ate--rial __--_--. - q� --------- No. of compartments. _.__...._ dept � C � Disposal Field: Distance from nearest well_.-r�J--U..._Distance from foundation___-�p.. s+ante to nearest lotline_... _-._ Number of lines._.-----.-.__-- e_�--�--"- Length of each line_�c9_yL_ --__--Width of trench-------- .Z� Type of filter materials c___&yc.•.,Depth of filter material____.__L__ ..---Total length__..._-_.7..�___---------------- Seepage Pit: Distance to nearest well---------------------Distance from foundation-______._...____Distance to nearest lot line_.........---- _ r ❑ Number of pits-------------------Lining material---------------.._Size: Diameter.--------------------Depth------------------------------ Cesspool: Distance from nearest well___.._..._.__.Distance from foundation---.___..._____...Lining material_._ ---_._..._--_..__------_.. ❑ _ Size: Diameter_----------------------------------Depth.---------------------------------------------Liquid Capacity--------------------------g Privy: Distance from nearest well-_.__..____..__._...._ ------..-_.._Distance from-nearest building .. _-:---_-_----_--. ❑ Distance to nearest lot line.__....__..._._..._.__--___--- ._ ----------------------------------- Remodeling and/or repairing (describe): - --------------------------------------------------------------------------------------------------- ----------------------- ------------------------------------- -- -- - -- -- -------------------------------------- I - -ereby certify the+ 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))e----- ' Qjip - i r - (Owner and/or Contractor) ---- -- ------------- By' ----------------------------------------------- Title (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 APPLICATION ACCEPTED BY--------- REVIEWEDBY---------------------------------------------------------------------------------------------------------- DATE-----------------_-- BUILDING PERMIT ISSUED--------------------- -- -------------------------------••--------------- - DATE---------------------- ------ - -- --- ------ Alterations and/or recommendations:..._.--------....---------------------------- ------- - - -------------------- - - - - - .... -- - - ---------- -- 11� :« i. -- FINAL INSPECTION BY:.___ _.//�� -_---_---___-.--_ Date........__ / i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Straat 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100