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y� Permit Na. APPLICATION FOR SANITATION PERMIT _---�?-1- ------r [ in Duplicate) �l (Complete P � Qate Issued Applica4-ion 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. v JOB ADDRESS AND LOCATION--------- ; -- ------------------------------------------------------------------ Owner's Name_________ _ _- _•?_-1 ,---------- Kz-�'--:-�"4. rt - ----------------= ---- - Phone------------------------------------ Address I ----------------- Eft... - �.._ Contractor's Name------- `K a 'is->=_ --------- ----------------------- Phone. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms ___�Number of baths --- _)___ Lot size ------;2 _.�'_1 ______________________ Water Supply: Public system Q Community system E] Private E] Depth to Water Table f ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ Previous Application Made: Yes ❑ No [k New Construction: Yes ❑ No ©` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T p6; sa nncee from nearest well_________________Distance from foundation--------------------Material___-_________________________________-_________- ❑ � a. of ompartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity....------------------- Disposal Field: �D��iis�st--a--;[nn—cc-e from nearest well___--------......Distance from foundation-_---_-___________.Distance to nearest lot line----------------- ❑ Zmi nber A lines-----------------------------------Length of each line--------_--------------------.Width of trench.---------------------------------- � Type of alter material-------------------------Depth of filter material--------.----..---F-_Total length___._______________-._______________`__ Seepage Pit: Distance to nearest well._.._ �1�-Distance from foundation____:_! ....... �} r� 7&--___- �+ ..___.Distant to nearest lot line____ Number of pits-------- ------------Lining material__ 'E_��___---- Diameter----.5-,-------.---.Depth-- ------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material ❑ 5ize:'DiametEr-~ - „�""'� �' - material_ _-____- Depth=------------------------------- --- -------- --- _- Li uid Ca acit ----------------------gals. Privy: Distance from nearest well-----------------------------------.-------------Distance from nearest building----------------------------------------- El --------------- ❑ Distance to nearest lot line----------------------------------------------------------------------- ------------------------------------------------------------------- Remodelingand/or repairing (describe):--------- -------------------------------------•--•---------•---------------------------------------------------------------------------------------- 1 -------------------- ---------------------------------------_______________»...-----------------------------------------------...._.----------------------------------------------------------------------------........--------------------------- --------- 1 ( hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat and rules qnd regulations of the San Joaquin Local Health District. ($i ned .1---- -----�-0=i' - ---------------------------------------------------------------(Owner and/or Contractor) 9 )---------- -SY� ---------------- (Title) �r--'--- ----------------------------------- (Plot plan, showing size of lot, location of system in relation to wells,,buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------- ------- ---------------------------------------- DATE---- ----------- REVIEWEDBY------------------------------------- ----------- --------------- ------------- -------------------•------------------------ DATE----- ---------------------------------------------------- BUILDINGPERMITISSUED-----------------------------------------------------------------------------------------•-----••---• DATE------------------------------------------------------------- Alterations and/or recommendations:----------------------------------------------------------------------------------------------------------------- ........-------------------------------- -------------------------------------------------------------- --------------------------------------------- -----------------------------------------------------•----------------------•------------------------------------ ---------------------------------------------------------------------------------- ------------------------------------------... ------------------------------ -----------------------------------------------.----- FINAL INSPECTION BY:. ------ ------------------ ---------- Date-----------I 'yamC ------------------------------- 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 FS-9-2 M Redised W-2100