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�' •• APPLICATION FOR SANITATION PERMIT Permit No. . ._ •} (Complete in Duplicate) Date Issued Applic on ii�ereby 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....-------//-��--------�-•------- - ---/--�--�-�---------------------------------• -----------==--------------------�- •- Owner�s Name-------------------- - ��l7 - K - �� --------- Phone-------------- - ----- .1 - 1AGY�---�------- --------_°--_-- Address c�i J---� ... �?� C l- ' --------• - �''� a' Contractor's Name--------------------------------- ------------------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: _ ___ Number of bedrooms ---- Number of baths __/___ Lot size ------ ________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobes Hardpan ❑ Previous Application Made: Yes ❑ No ❑ 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--_,!�- -/`t 1?istance from�foun*on-----14,Hc-r-Material_________________---__'___-_____-____-_...___.__. No. of compartmentsSize______. -_ p9 3--X.�.---Liquid depth_-----��-----------------Capacity---� -�� - -� Disposal Field: Distance from nearest well__�D/�+-, Distance from foundation-----/4_A,-c.Distance to nearest lot line__:_.- Number of lines----------- Length of each lin G1 ---------.Width of trench------c;l ---------------- Type `------------Type of filter material.Z-�4-t__ __Depth of filter .material-------/9_-_.__._Total length---.---64--------------------------- Seepage _________________________Seepage Pit-. Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line________________ ILI ❑ Number of Pjts-------------- ----Linin9 material---------__--. ---- `Size: Diameter-----------------------Depth------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------_--.__ [\ ❑ Size: Diameter--------------------------A--f:----Depth---------------i------------------------------------Liquid Capacity.---------------------------gals. \? Privy: Distance from nearest well _._.___________________Distance from nearest building-------------------------- ❑ Distance to nearest lot line--------------------------------------------------------------------------------------•----<-- ----------------------------------------------- Remodeling and/or repairing (describe):---- +---------- ----------------------------------------------------------------•-- ---------------------------------------------------------------- r ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ I ---------------------------------------------- I hereby certify that 1 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 L�al Health District. (Signed) - - ------------- -------------------------------------------- ----------------- ------------------- Owner and/or Contractor) ..... ---- - ------------------------- Title ------- --------- ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPART.Y T USAONLY APPLICATION ACCEPTED BY------------ c. e - ----- ------- ------- ATE----------! -------------- REVIEWEDBY--•-------------------------------- ---------------------------------------------F------------------------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED ".-=�----------------------- DATE------ --------------------------------------- Al+era+ions and/or recommendations---- ---- -------- ------ -- ---------.--------------.-..._..-----____-- ----------- D �` �Q -----------••--- ---- -- -6 j�. _s3 C, - ---------- FINAL INSPECTION BY:-----------1�.. __' 6 �__tr!_L_-r------------- Date.....---,1_..- --��--------�--�------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street _e 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 I