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APPLICATION FOR SANITATION PERMIT Permit N.,;2-!q---17----- (Complete in Duplicate) Date Issued� r- 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. S49. S ! ------------------------------------------ A-PR - ------- JOB ADDRESS AND LOCATION--- �--�--- ---------------- - ------------------------- --•-- �n Owner's Name �'J ' !_�a. -�---- Phone -------------------- --------------------------------- Owner's : -. -------------------------------------------- --------------------------------------------- ---------------- Contractor's Name------------------------------------------- Phone----------------------------------- ------------------ Installation will serve: Residence J� Apartment House ❑ Commercial [I Trailer Court ❑ Motel ❑ Other ❑ f Number of living units: ________ Number of bedrooms ---%3-- Number of baths __)_____ Lot size ---------I_. ----- ----------------- C----- - Is ft 1 Water Supply: Public system El Community system ❑ Private ' Depth to Water Table __ i Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam [:] Clay Loam ❑ Clay [-] Adobe E] Hardpan A Previous Application Made: Yes NoIVNew Construction: YesZ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: v (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Materia!_________-___________________________________.� yr -+'? No. of compartments--------------------------Size--------------------------------Liquid dept--------------------- Capac:ty ---------- -- „ ext W 5----Distance from foundation- 3_s5-----.Distance to nearest lot line Disposal Field: Distance from nearest well______ _ Number of lines-----------------------Y --=---------Length of each line---------E0-0----�-----Width of trench----------- ------------------ F Type of filter material_------ - ir_lr ��----Depth of filter material-------- ' ---------Total length--------- -1�-¢------------------------- 1 arest lot line_________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to ne ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material-----------------------------------_- -----------Liquid Capacity----------------------- ----ga ❑ Size: Diameter--------------------------------------Depth----- -------------- ------------ - ls. ► Distance from nearest building ----- Privy: Distance from nearest well ----------------------------------------- 9 -------------- ------------- - I ❑ Distance to nearest lot line_________________ -------------------------- Remodeling and/or repairing (describe)-------------- �'� - r- ------------------------------------------ � --- --------- ------------------ ------------------ --------------------------------------------------------------------------------------- - =--------------- -------------------------------------------------- a I hereby certify that I have prepared this application and that the work wi be done in accordance with San Joaquin County ordinances, State laws, ands`les and regulations of the San Joaquin Local Health District. d ---------------------------------------------------------------------------------(Owner and/or Contractor) (Signe i9ne ) t ; -- -- - --- ---------- -- -------- ---------------- Tale = -- ----------------------- ------------------------------------- 1 (Plot 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----------- --- ------------------ ------------------- DATE--------- --------------------------��- - ------------------------------- - --- ---- ------- - - ------------ REVIEWED BY----------------------------------------------------------------- DATE--------- BUILDING PERMIT ISSUED--------------------------------------------------------------- ------------------- DATE I Alterations and/or recommendations-------------------------------- --•-------- ---------------------------- ------- --------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ -------- --- ----- ------------------------------------------------------------- -------------- -------- ----------- ------------- ---- ----------------- ---------------- ------------ ----- i FINAL INSPECTION BY:--------W 1l Date-------------I---1------- (: -----�1----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT F 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