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r* APPLICATION FOR SANITATION PERMIT Permit No. ------------------ Y � - (Complete in Duplicate) . .3 .S'A Date Issued Application 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....---.1 -a_ _-- --. ___-- --------- ----- --------1-r----•--- -- Owner's Name------------------------------------- S 1 / .;��------_----------------- ------- Phone----------•------------------------ -••------ Address =- --------------- 1 Contractor's Name_ j �` " ^' ti ------------------•----•-------- Phone----••--------------•------------ i a Installation will serve: `Residence i Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑_ Other ` 3-4 d Number of living units: __ -____ Number of bedrooms __ -. Num . - ber 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 ❑ Adobe ©..-I Iardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes U--I�o ❑ } .TYPE OF INSTALLATION AND SPECIFICATIONS: ' ( osePt'c tank : cesspool lP permitted if available n- Distancefromneasteii�l � Distance dSeptic Tank: ;i: 'Mater ' '-_-`"�" . '�- Noof compartments------�--------------Size---4XS _ Liquid depth------------------ .a-Capacity--�-_-_-_--je0--_-- l__Dil Field: Distance from nearest well......7. Istance from foundation__-__�Q--------Distance to nearest lot line____ Number of lines__= --- Length of each line___:___--6 Q__- -- -_---Width of trench----___-__- ¢._��-._�-_-_- Type of filter material . Depth of filter material-------/27___-'---Total length-------------------__----------______-__ Seepage Pit: Distance to nearest well__________________Distance from foundation--------------------Distance to nearest lot line-------.--------- ❑ Number of pits--- -----------------Lining material.--------------------- Size: Diameter----------------------.Depth---------------------------- Cesspool: Distance from neI arest well-----------------Distance from foundation___._.__-_-_-____-:Lining material----.-______---_------_-----_-_-_____. , / 1 n ❑ Size Diameter--- ----------------------- �e�t„h - __ - r -Liquid—Cap ac�fy -'"ter—a� . _ �, ., Privy: Distance from nearest well-____________ __ ____________--_-__________Distance from nearesf building__-_- ❑ Distance to nearest lot line-------------------------- -•---------------- -------------------- y-- ------------------------------ Remodelingand/or repairing (describe)---------------------------------------------------------------•---------------------------------------------------------------------- -------------••---. ----------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- ------------------------------------------------------- -------------------- •-- --------------=-----------------------------------------------------•------------------------------- -------------------•--------------------------------------------------------------------------- - 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. 4 I (SignedB)_ :..- _ ? ( (Owner and/or Contractor) �"..------------------------------- -------------------------------- (Plot plan,, howing size of lot, locton of system in relation to wells, buildings, etc.,,can be placed on reverse side). a f t - FOR DEPARTMENT USE ONLY a ACCEPTED BY ; -- --tea--- ----...� ------`DATE------------ f /,_� - -------------------- APPLICATION - t = --------- ------------------------- -1- -• - DATE-------------- --------- REVIEWED BY----------------------------------- --`----- ---�------------------ --<--------- ---- - BUILDINGPERMIT ISSUED---------------------------- ----------------- --------------------1------- DATE--------------------------------------------------------- Alterations and/or recon•emendations:---------------------------- =------ t -----------------------------•-----------_------------------------•---• -----------------------------------------..---------------------------------------------------------------------------------------------------------- ------------------- --------------------------------•------------•--•--•---•--•---------•----------------------------- •-----------•--- -------------------------------------------------•-------------------- ------------ ------------------------------------------------------------------------------------------- FINAL INSPECTION BY:. Date-------- / `S 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