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�5X APPLICATION FOR SANITATION PERMIT Permit NoY1a_ ` (Complete in Duplicate) i \�y V Date Issued A lication is hereby m pp y 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-------------------- . _ _ Owner's Name-------- :'-;'---!__!-f /Z."•1 d�_ Phone —y -------------------- - Address ---------- Contractor's Nama / -1-------- ------------ -- ----------- Phone Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Number of living units: ________ Number of bedrooms ---/.. Number of baths __1___ Lot size IWX_____ --------__ ------ Water Supply:` Public systemX 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 [V New Construction: Yes X No ❑ TYPE'OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) { Septic Tank: Distance from nearest well----"—__..__Distance fro fou dation-JO-10-'-f--..Mater�l________ ____________..._---____ , No. of corrpartments---------�`----------Size----.3xx�-----Liquid depth------�_D��------Capacity____ d- ---- Dis osaI Field: Distance from nearest weli------------Distance from.foundation�___JO1U_�--- Distance to nearest lot line__. ~I-___ Number of lines------------ ---- Length of each line____ ,,// /1' 4I 9 �v--4---- --- -- - Width of trench-----a-�---------------- O Type of filter material_____ ._ .Depth of filter material----I�-_________..Total length--------f_ ---_--- Seepage Pit: Distance to nearest well-----.------------.---Distance from'foundation-------------------.Distance to nearest lot line_____..._______ ❑ Number of pits------=---------------Lining material------------------:'_.Size: Diameter-----------------------Depth--------------------------------- Cesspool: ------------------ --Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_---_-..________________--_-__.______- Ul ❑ Size: C3iameter---------------------------------------Depth------------------------ ------ 1 ----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-___--__-_._--.__.___________________________---Distance from nearest building------------------------------------------ El Distance to nearest lot lire__________"_______________ - =---------------- Remodelingand/or repairing (descr;be):-------- ------- -----------------------------------....------------------------------------------------------------------------------------------•---- -••--------------------------------------•--------------•-----------------•--•----------- -------------•--------------•-----•-----••------------- ----------------------------•--------------------------- -- 4 ______________________________________________________________________________________.----_________________. ._ 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. l (Signed)------------------------------------------------------ - - (Owner and/or Contractor) --- -- ------ --- -- _F • A ~J f ----- By: -------- --------------------- ----- c (Title) = (Plot plan, showin siz o lot, location of system in rela ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ---------------- ---------------------------•-------------------------- DATE------------------------- REVIEWED 'BY------- -------------------- - ((//�� ---------------------------- DATE-------------- -------- PERMIT ISSUED --------------•-------------------------------------------- DATE------- 1 r� -------•-------- Alterations and/or recommendations:___.___. --•------------------------------------------------------------------------•-------------------------•------�--•------------------------•-•------•------------•----------- .-------•---------------------------------------- ----------•--••----------------- --------------•- ---------------------------------------------•--------- -------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ ----------------------- -- 3. FINAL INSPECTION BY:-.--,- ----- - --- ------------- Date---------------- �----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California- Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 r