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` r { 1 APPLICATION FOR SANITATION PERMIT Permit No. ..... ._ 1 (Complete in Duplicate) II J Date Issued -- Appiica-lion 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 ounty Ordinance No. 549. B ADDRESS AND LOCA?9N 5--- -[.l /...1�--�-------- -- - + 0 Owner's Name------------- -------- d _ Phone: . J Address-----------•----------- f}l1 -----------------------------------------------------------•---------------------------------------- -------------------------------- - •, Phone- 1.��" f Contractor's Name----------------- - / _A-'� �` Installation will serve: 'Residence X Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other [I Number of living units: _�-- Number of bedrooms - Number of baths _J-_-- Lot size --- -K- _- - ------------------------- Water Supply: Public system Communitysystem E]'-Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑' No V New Construction. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:SWC, Distance from nearest well------ -----_Distance from foundation-------------------Materiai------------------------------------------------- ❑ IS7" No. of compartments---- -------------------Size--------------------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well---.------ Distance from foundation--------------------Distance to nearest lot line----------------- ❑ �K1s Number of lines.---•------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------------Total length---._--..-__-----_---------_--_----_----- Seepage Pit: Distance to nearest well_NJ9 4°.�------Distance from foundation-_-; ----------Distance to nearest lot line__-{----_ Number of pits-,0-/V�------Lining materia r +/'�✓--_.Size: Diameter---- �-----.----.Depth-- - ---__--_ Cesspool: Distance from nearest well-----------------Distance from foundation-------.-.-_--_.--.Lining material------.-..- ❑ Size: Diameter------ -------------------------------Depth--------------:-i---------- ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------- -- Distance from nearest building—-----------.-----_-._-_--_-.--------._. ElDistance to nearest lot line----------------------------------------------------------=--------------------------------------------------------------------------------- Remodeling and/or repairing (describe)*:--" -` ------------- - T 1111----------rw - '?% ��" if!Yfl ". ------------------------------------- -----------------------------------...------- - ------------------------------------ -------------------------------------------I----------------------I----------------------------------------------------------------------------------------------------- -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that] 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. Y (Owner and/or ontractor) ---- - ------ --.�-------------------------------------- (Signed)--------------------- -- 1 ------- - ----------- --- --- ----- - ---- - (Title) ! (Plot plan, showing size of lot, location of system in re to wells, buildings, etc., can be plat on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------- ---- --- - ---------------------------------•---------------------------- DATE---------- --------------------------------------- REVIEWEDBY; DATE------------------ -----•--•-------------------------------- DATE.. -. BUILDING PERMIT ISSUED--------------------- -------- -- -_�---{{-��,, �---------•---- ---•----------- Alterations and/or recommendations:--------------•=- V--------- ------ ---------------------------------------------•---------•----------------•-------•-- � --•------------------------------- --------------------• ----------•------------------------------------------------------- ---•----- --•-------•--------•- -------------------------------------------------------------- -----------------------------------------------------•------------------•---•-----------...----------- ---------- ----- Date--- "' ----------------------- FINAL INSPECTION BY-- --=--- -- -- ---�---------=--- =----=------ ----- --- 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