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APPLICATION FOR SANITATION PERMIT Permit No. __j.-V____-- (Complete in Duplicate) I Date issued i 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. 1 j JOB ADDRESS AND LOCAT N-- O = ------------- _---- ------- k.�?_�fj------------------------------------------------------ Owner's Name 1_--Q f�� ------------------------------ Phone -------------------- ----------------- Address-------------•---------------------•---------------- 1 M --•--•---------•------------------------- Contractor's Name------------------- �'3 V f Phone- ----- Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - umber of bedrooms _- Number of baths - Lot size ----------- _ '�----- - ------------------•-- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay p ❑ Y ❑ Y ❑ y ❑ Adobe, Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes & No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well-', ell _ Distance fro fouQ ation- -_ ! �}. - ��-- Mat ---.--G�A_�-�--��'-----------•----- No. of compartments--------�----------Size-- - - - E--- -- -----Liquid depth--------.Z7-------------Capacity-_-�-�t r 4 .. Disposa4Field: Distance from nearest well--____'.�'�""__Distance from foundatio --- _�� Distance to nearest lot t�e----.�-_-_-. Number of lines-R.........1�-------- Length of each line ----.-- __--_ ; _Width of french------- -------------- Type of filter matorial.__ _ ©-- - De th of filter material____-_- p �-;�----r---Total length------••-��----------I---�------ Seepa Pit: Distance to nearest yfell------:=-_______Distance from foundation-__-_-� ---__.Distance to nearest lot line_R---- Number _ Number of pits_________ -----------Lining material--6TK,4--------Size: Diameter-_---__—L41—____-_--Depth______-a-'" 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):__--. _ - _ _______-__ �� .� ---------------------- -------------------------- ----- ---- ----- - - t --------------•----------•--------- --------------------•---------------------•--•------------ -----------•-------------•---------•----------------------------------------------- •------------------------------------------------- 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 a regulations of the San Joaquin Local Health District. s I ' (Signed)- -------- r -------- ------------------------------------------- (Owner and/or Contractor) By-------------------_-----------------------:�.. ---------------------------------------------------------=----(Title)----------------------- (Piot 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---------- - ---------------------------------- --------------------------------- HATE-------------- - ------ - - -- - ------------------ REVIEWED BY ' -------------------------------------- ------------------------------------------ -- - DATE BUILDING ------------------------ PERMIT ISSUED Alterations and/or recommendations:--------------------------------------------------- ------------------------------- •------------------•- -+ -4--------I W------- ------------ ------------ --------------------------------------------- -� '-------I----------------- ----------------------- ---------------------------- -------------------------------------------------------- I - ----------------- FINAL INSPECTION BY-------------- _ Date - ------ ----•-------- -------------------------- SAN --------- --- - 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 B-51 Revised W-2100