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1 APPLICATION FOR SANITATION PERMIT Permit No�Vreindescribed. (Complete in Duplicate) ; .: Date Issue -=--- Applica*ion is hereby made to the San Joaquin Local Health District for a permit to coAstruct and install the work h This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN LOCATION...._ -?-!_ ______. _____ ` } Owner's Name tl �1 j ---------------------------- - ------ Phone, '- � Address--------------------`3 / - ,. `' - ------------- ------=-- / �J Contractor's Name----- _•--•__--__--- ___ ------ ___._ Phon .- --lz__ Installation will serve: Residence g---Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -__ m.ber.of.bedrooms ---.___ Number of baths,,/----- Lot size _1491____________________ Water Supply: Public system �Gom`mu ity sr ystem ate ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Grave ❑ Sandy Loam ❑., Clay Loam E] Clay ❑ Adobe ffZHardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No � . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is vailable within 200 feed.} Septic nk: Distance from nearest well---- � Dista ce��ro/m `ou,/nudation:____4:______ ___Mate 1-1142- ------ .________ ..p--_-.- _• No. of compartments_______s�_-_-_ __ _.-►--Size,a _.-e� o __1s_!e�___Liquid depth____-_ -_capacity.... l Disposal Fi Id: Distance from nearest well-.-. e < Distance from foundation_______------._.Distance to nearest lot��i ❑ .3 Number of lines____________ _�74 ' `_`___--_Length of each line______________._ Width of trench__ _ _�X(�(� Type of filter materia_ - ---' J Depth of aterial- �- ---------Total length-----------------------------•----------- Seepage Pit: Distance to nearest well_____7 _____ ante room fou}' on______ __________Distance to nearest lot line____4_ Number of pits.....f_------________Lining aterial_Cr__ _G4 '- 6 -.,iz Diameter_____�-`-........Depth__�•�_r_--_____________ Cesspool: Distance from nearest well-----------------Di un ation-_--_-_.___.__---_ Lining material---------------.--------------------_. ❑ Size: Diameter-----------------------------------=--Depth---------- ---.-----.--------- ---------------------Liquid Capacity---------------------------gals. Privy: Distance from Barest well---_---------------------------------------------Distance from nearest building------------------------------------------ L1 Distance to nearest lot line------ -- --=---------- -----------------------------------------------•------------------------------------------------------ V + Remodeling and/or repairing (describe)------------------------------------------------------------ '-------------.. 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, State iaws and rules and regulations of the San Joaquin Local Health District- . (Signed) ------ - . t Contractor) ------------------- __ tgr• -- --------------------------------------(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 ACCEPTEDBY --------- DATE I— REVIEWEDBY---------------------------- ------ ------------------------------------------------------- ------------------------- DATE ,�-------•------- BUILDINPERMIT ISSUED---- J------------------------------------------------------ DATE----------�— ------------------------------- ---------- Alterafi and/or recomm6 ations:--------- ------------------------ - ---------------- .._. . z------•---------- ------------------ --�-- :-::______--- - --------•---------------------- -----------------------------------•------------ -------------------------_-------------------------------------------•--------------------------- ----------- -•--------------------------------------------------------------- --------------------------- ------ L11 FINAL INSPECTION BY:---------------------------------------------------------------- Date----- ------------------------------------- -Z 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