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1 �y APPLICATION FOR SANITATION PERMIT Permit No.�--�-5.... i I (Complete in Duplicate) //2 3.Y - Date Issued l--_�_ �______________ PA l Applica{ion is hereby made to the San-J6aquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with Cou ty Ordinance No. 549. ` �� . JOB ADDRESS AND L CATION -----------_-- •la �j �*�- Owner's Name ------------------------------•------------------------- ------------ ------ PhA------------.•---------------------- Address. •------- - -----------------------•------------------•------------------------------ -------------------------------------------- Contractor's Name----- - - -- ---------------------------------------------------------------------------------------- •---------------------- Phone_1�V--`s --12116 Installation will serve: Residence Pg/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �y / Number of living units: ________ Number of bedrooms __� Number of baths -_Z__ Lot size ------ 9_0 �--------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _ld ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [:] Clay Loam ❑ Clay [] Adobe Q_Hardpan ❑ Previous Application Made: Yes ❑ No 2New Construction: Yes � o ❑ 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-�_d-------- Distance from four dation___1_P_.__..__ Material_ .!_----- "___ No. of compartments---------------------- 5ize__ E+_Xy4------- Liquid /depth....... ----------- Capacity---- Disposal Field: Distance from nearest well _S6---------- Distance from 4 foundatiaff''..---J-_ ..__Distance to nearest lot line__��t______ ©� Number of lines -------- /-------------- __ Length of each line_____ 6_6__'_............... Width of trench.___ -S! ��_____-___________ Type of filter malarial_St_ ------ Depth of filter material'-___l _....___.__Total length ------- C_ ...___________________ 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 -------------------------------------- El Size: Diameter-------------------------------------- Depth----------•---------------------------------------- Liquid Capacity ---------------------------- gals. V Privy: Distance from nearest well-__.._.__- ---------------------------------- Distance from nearest building __--_____._____________-..--------------- ❑ Distance to nearest lot line ----------------------------------------------- ------------------------------------------- Remodeling ----------------------------------------- Remodeling and/or repairing ( cribej:__-�ik/�-._ -----_�, ' �_____ _____ ------ -- - --- -- 14 ----------------- - i�- ------------------:----------------------------••--------- -1--------••--•-•------------•-----------1------•-------------------•-----....------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, �S laws, and_,r.ules and regulations of the San Joaquin Local Health District. (Signed}_.__. f --- {Owner and/or Contractor} - f �`----------------------------------------------- ...(rifle) (Plot plan, showing size of lot, location of sys m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------- -- ----------------- ---- DATE -- lam' REVIEWED BY - -- ------------------------------- ------------------------------------------ DATE---------------` BUILDING PERMIT ISSUED-------•---------------------------------------------------•---LL------------------------- ------ DATE --------------------------------------- Alterations and/or recommendations-----------------------------------------------------•---------------------•---------------....". -------------------------------------------------------------------•-------- ----------------------------------------------- ----------------------------------------- •-------•----------------------•----------------- ----------------- ------------------------------- ------------------ FINAL INSPECTION BY:. if+'�r`-------------------- -------------- Date-------- C-- 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