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1 APPLICATION FOR SANITATION PERMIT Permit No. �I (Complete in Duplicate) � S .,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.. -- " 9 Phone Owner's Name - . . ..----- ' r- --- .. r 11111", ------------ Address.-----�--3.-- ------ - °�_� : ------. Phone----- Contractor's Name-----.r ' ��-------- -------------------------------------- Motes Other ❑ Installation will serve: ' Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑ *'7'Z/,3,-- Number of living units: _ -" Number of bedrooms _ - Number�f baths A. Lot size - ---------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _ - tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [-IClay Loam ❑ Clay E] Adobe Hardpan ] Previous Application Made: Yes E] No New Construction: Yes w No ❑ �p TYPE OF INSTALLATION AND SPECIFICATIONS: �C (No septic tank or cesspool permitted if public sewer is available within 200 feet.) a ' Material Septic Tank: Distance from nearest well._._______---Distance from foundation__. __. e No. of compartments---------0--------------Size__ '_ y4_, VU'iquid depth-----------5 -----------Capacity-----/_.lA_9--- X i ��ryry �4 �.".Distance to nearest lot line '�_--_---" Disposal Field: Distance from nearest well---<.-._..__._-Distance from foundation_._ _ ,- Number o{ lines_-_______._.�-_."-__-" -- Length of each line-----/- Q"�__---- -.-.Width of trench_ _____ __ Type of filter mate rial__-4 __--Depth of filter material__-..___`. ----.._Total length"_----IRA ________________•----- Seepage Pit: Distance to nearest well[----------------------Distance from foundation--"-----___.-__"_-.Distance to nearest lot line-------------------- 0 ------ --- Number of pits-----� --------- -Lining ma#erial-----------------------Size: Diameter-----------------------Depth----- -------------- Cesspool: Distance from nearest wei4-----------------Distance from foundation--------------------Lining material_--___----_--."---___---__.__._----_. ❑ Depth -----------------------Liquid Capacity----------------------------gals. Size: Diameter------------------------------- - ri Distance from nearest bus{din Privy: Distance from nearest well."--- --------------------- g - - ------- ❑ --------•------------------- Distance to nearest lot line-----�-- ----------- ----------- ------------ --------------------------- -------------- i Remodels a /or repairing-0esc ia-, ------------------------------ ----------------"------- - - --------------------------------------------- -------------------------------------------------- -• ---------------- ----------------- ----------------------------------------------------- --------------------------- -----------------------•---- ---•--- ------------ ------------------ ------ ill be done in accordance with San Joaquin Caunfy�j� E 1 hereby certify that I have prepared this application and that the work w Y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. \ I (�caner and/or Conracte4= r -------------------------------- (Signed)-------- = r. 1 ------------------ ----- BY� i -------------------------- (Title) --------------- ------ (Plot plan, showing size of lot, location of system ' relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. --------- ---- --------------------------- DAT _ REVIEWED8Y ------------------------------------------------------------ DATE__ ----- BUILDING PERMIT ISSUED--------------------- -------- -•--- DATE Alterations andfor recommen ations:__.________________________________________. -- --------------------------- ----•----------------------------------------------- 4 - ---------- ------•------------------ ----- y [!, 1 _FINAL INSPECTION" BY:---- ------ - --- -- -- -�- - - - -- --- ------------ ---- Date-- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 914 North "C" Street !30 South-Am Street 300 West Oak Street Y Lodi, California Manteca, California Tracy, California Stockton, California i ES-9-21M'h0-52-Revised W-2100, --�