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f� APPLICATION FOR SANITATION PERMIT Permit No. _____ N j l (Complete in Duplicate) ,�-•f 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......� - � �- ------------------------------------------------------------------------------------- Owners Name---------------- = y ---------------------------------------------------- Phone-------------------------------- Address----------------------- -------•------------- --------Address----------------------- . --- ..:---• f -------- •-••--•---- - ___ ri -------------------------------------------------------------- ___________________ -Contractor's Name---- __ _____ _ hone_ -- Installation I will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ 1 Number of living units: __2--115'mber of bedrooms _�,�,__ Number of baths __4--tot size __�__�" ___k- Water Supply: Public system ❑ Community system ' ] Privateepth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Q Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes E] No lew Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: } oseptic tank cesspool permitted lJf pubseweravailable within 200 feet.] Septic Tank: Distance nearest ef �__' Distance � from foundation----1-�------.Material------ao;P�V_el_ t------ + -----------Size____ _ __L _ "Liquid depth________J�__________Capacity____4 _ 1 _ No. of compartments-----------t , Disposal Field: Distance from nearest welI -------Distance from foundation_____ _.Distance to nearest lotqiin______________ __Length of each line___' Q________-_______-Width of trench_____ __Number of lines_ ___________ ----------------- of filter materiai_______l___- _ e th of filter material--- -�----.--Total length--_p g --- -- -------------- Type Seepage Pit: Distance to nearest well_____ _____________Distance from 4oundation--------------------Distance to nearest lot line-_____:_____-_ ❑ Number of pits----------------------Lining material-----------,.------------Size: Diameter------------------------Dept h----------_---------------------- Cesspool: Distance from nearest well_______________Distance;from foundation____________________Lining�ma.ter.iaL_.__,_______--_ _ :___.::.. ., ❑ Size'�Diemeter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------- ------gals. { Privy: Distance from nearest well------ ------------------------------------------Distance from nearest building-------------------------------- -------- ❑ Distance to nearest lot lire_____________________ Remodeling and/or epairing (describe):----------- __ _. . -__ ------- F _____ ..r..... I _t----------------------------------- F ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- 1 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. i (Signed)---------- ----- - ----------------(Owner and/or Contractor) $Y' n-0 - - 4---------------------------------------------------------------------------(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---------;------------- .... _�- --------------------------------------------- DATE-------- -- - - ------------------------ REVIEWEDBY--------------------------------------------- --------------------------------------------=----------------------------------- DATE--------------------------------- BUILDING PERMITISSUED-------•------------------------------------------------- -------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations-------------------------------- --------------------------------------------------------------------=-----------------------•------•------------------ --------------------------------------------------------•--------------•--------•---------------------------------------•------------------------------------------------------------•----------•------------••----------•--- ----------------------------------------------------------------------------------------------------------- ---- --- ------------------------------------------------------- ---------------------------------------- t FINAL INSPECTION BY:_____*W__ Date... / d` I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West OakStreet132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California p €S-9-2M 8-51 Revised W-2100 - s 4 i