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r �,�`` J APPLICATION FOR SANITATION PERMIT Permit No, ------------------ (Complete _ __. (Complete in Duplicate) q 1 0� Date Issued ____ Applicatio s hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appli ation is made in compliance with CounLy "dinance No. 549. JOB ADDRESS APD LOC TION-! �.. - .Z a4xe-j-- I ---------------------------------------------- -- Owner's Name---- --- ---- ---- _ Phone-->5` ----------- Address ----- Address------------f �� m`-7--•- -- k- ------ Contractor's Name-_?t^-t _!f�--- - --- ------ - ----- ------------------------------------------------------------------------------------------- Phone- `S. Installation will se(verJResidence Apartment House ❑ Commercial ❑ Trail r1Court ❑ Motel ❑ Other ❑ it r Number of living units: ___I___ Number of bedrooms __fu__ Number o aths ___ ____ Lot size __��____�_�`�__t,!____________________________ Wa+er Supply: Public system ❑ Community system ❑ Private Depth to Water Table ________ ft. - Character of soil to a depth of 3 feet: Sand I Gravel E] Sandy Loam f _ Clay Loam ❑ Clay El Adobe Hardpan E] { Previous Application Made: Yes ❑ No New Construction: Yes [ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s�wer is available within 200 fee+.) r Septic ank: Distance from nearest well___ ___Distanc 1from founds Maters I____ _____________ __._ No. of compartments------------ -- ------'__Size---'T-nC49-_d&Liquid depth----------- -----_-_-_Capacity_. __ _{!_ _ Dispos Field: Distance from nearest weW11- r _ Distance from foundation ___�} 1_ Distance to nearest Ipt li e�� `� 9 6--C� (-'-.Width of trench ---/-- ---------:r Yp Number of lines----__- { ®epthhofffiltemlaterial_ __---- - j_�r____Total length----- _--- "T e of filter maters 1 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 nearest well-----------------Distance from foundation--------------------Lining material.-________._________________---_-__--. [❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------------•--gals. Privy: Distance from nearest well________________________________T~_______-_Distance from nearest ------------------------------------ ❑ Distance to nearest lot line----------------- -----------------------------------------------------------------------------------------------------••----•---------------- Remodeling and/or repairing (describe)__________________________________ ---------- --------------------------- - ' -------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ------------------------------•---------------- -------------------------------------------•--------------------------------------------------•--•-------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------•--------------------------------------------------------------•---------------------------------------------•----------•----•---------•-------- I hereby certify that 1 have prepared this application and +hat 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:----------•en--•--• '=' ' "��----------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, shot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . __---------------- ------------------------------------------------------------------ DATE_ ------------------------------------------------- - REVIEWEDBY-------------------------------- V. ----------------------------------------------------------------------------- DATE---- ---------------------------------------------------- BUILDING PERMIT ISSUED------------- DATE ------------------------------------------------ Alterations ---------------------•- Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------------------------------------------------------•--- ---_------•----------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------•---- -----------------------•-------------------•--•------------------------------------------------•----------- ------------------------------------------------------------------------------------------•----------------------- ------------------------------------------------------------------•--------------------------------------------- -------------------------------------------------•-------•-------------------------------------------------- � FINAL INSPECTION BY-------- ---------------- Date-------------� /d---f/ � --------------------------------------------- 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 8-51 Revised W-2100