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Al' 'CATION FOR SANITATION PERI Permit No. '_ _ .� (Complete in Duplicate) 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------- �_ _ ��T. � Owner's Name---------------W}-Al...--• ` .i�a --------------------------------------------------------------------------------------------- Phone------------------------------------ Address-----------------------------------1._Z 9--•-•-.sc Contractor's Name----------------------------------------------------------------------------------------------------------------------------------- ---------- Phone---------------------------------- Installation will serve: Residence © Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/____ Number of bedrooms Z___ Number of baths _f.._. Lot size ------�3-_> --_.___-_____._._. 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 © Hardpan ❑ Previous Application Made: Yes, ' No R New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ��-yy Septic Tank: Distance from nearest well..... Distance from foundation__-_�"-_.____.Material____(2.r -<< _�Q -�• ® No. of compartments------ ______________Size__?_X___L---X__-�-----Liquid depth-------:5 __.---------Capacity___ Disposal Field: Distance from nearest well__SP__'____._Distance from foundation____ --------Distance to nearest lot line___ ----------- ® Number of lines_.______._______-__-_____--___Length of each line_ _ __ _1 F" __.Width of trench__..._3_y_`�________________ n Type of filter material_-:—_."-- _____Depth of filter materiaL___) _____Total length______-1_.�._ _______-__•--_-__ Seepage Pit: Distance to nearest well---------------------- 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-------------------------------------------------Distance from nearest building___--___-__-___•_-___-_--_-_-_______-____. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------•-------- Remodeling and/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. (Signed)---------- -- -------------- - -- ---- --------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------- ------ --------------------------------------------(Title)------------------------------------------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR EPARTMENT USE ONLY �y APPLICATION ACCEPTED BY------ ----- --------------- DATE-------/ - ----------------- REVIEWEDBY-------------------------------------------..-------------------------------------------------------------------------------- DATE------ ---------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.----------------------------------- ---------------------- Alterationsand/or recommendations-------------------------- ----------------•--------•--------•---••-•-------•-----------------------------------------------------------------------------_----- ------------------- -------- --------------------------------- ---------------------------------------------------------------------------------- ----------------------------------- ------------------------------- ---------------------------------------------------------------•------------------------•---------------------•------------------------•-----------------------------------------------------------------•------------------ --------------------------------•-------•---------------------------------------------------------•-----------------------------•---------------•----------------------------------------------------------•----------------- FINAL INSPECTION BY:-.------ -- = Date-- ----- � --- ------------------------------- � 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