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I4VAPPLICATION FOR SANITATION PERMIT Permit No. _ � ._...___� (Complete in Duplicate) Date Issueely- fl-I u`�`y 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.., o ,p� � -----�'-----------------------------------•--------------- f Owner's Name--------------oc `_s ' "fi M - --------------------------- Phone"Z&-- •''------- Address--------------- SIP-7,14�--------•-------------------------------------------------- Contractor's Name-------7"'7�------------------------------------------------------------------------------------------------------------- Phone-------•--- ---------------------- Installation will serve: Residence9 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � Number of living units: / Number of bedrooms-- Number of baths J___- Lot size irex-4e_____________________________________ +. Water Supply: Public system 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 [` New Construction: Yes ❑ No ❑ 'Y 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_D f-----_Distance from foundation-J a----_____.Material______________________ No. of compartments______ ___________Size_X _X__�J�_- � [7 y 1 ,pp ��J --------Liquid depth --- �-----------Capac�tY---�---------- ---- Disposal Field: Distance from nearest well*v' --------Distance from foundation__1_�- _____-Distance to nearest lot €ine�_�______ �j Number of lines---1" ______ r----_-Length of each line_�fD 70--------.Width of trench_�4�-'-------------------- �. Type of filter material_ _________Depth of filter material____11-- _._Total length-___/1_�_________________________ } Seepage Pit: Distance of to nearest wellpits = =__Linin material from foundation Diamater- Distance to nearest lot line______ ________1-1 �; Lining ------Depth--------------------------------- cesspool-, Distance from nearest well-----------------Distance from foundation--------------------Lining material________-_-_----__________________--. ❑ Size: Diameter-----------------------------------Depth---•----------------- -----------------------------Liquid Capacity---------------- 9 - ----------- els. Privy: Distance from nearest well-------------------------------------------------Distance' from nearest building------------------------------------------ El Distance to nearest lot line----------------- -r=-- .-------------------------- - Remodeling and/or repairing (dsscribe):->, --- ---. ,.�..vf,G..�------------------------•-------------- ---------------•----------------------•--------------------------------------------•------------- -------------------------------- ------------------- ------- ---------------- --- ------------------------------------------------------------I-----------------------------•------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ti ordinances, State laws and rules and regulations of the San Joaquin Local Health District. (Signed)------- P _ --------- - - _ , (Owner and/or'Contractor)- ----- --- --------------------- -- -- - --------------- By:----•----------------------------------- ------ -----------------------------------------------------------------------------(Title)------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). j FOR DEPARTMENT USE ONLY BY--------------------ae---------•------------------- ------------------------------------------ DATE ¢ ' -------- = - APPLICATION ACCEPTED := --------------------------------------------------------- DATE l /—1�' _ C -------------- BUILDING NG P R -MIT ISSUED - �d/�L'f� - r ----------------------------------- DATE------------ Alterations and/or recommendations:--F------------ ----------------------------------- -------- ------- -- - 14.)-------------------------------------------------------------------- - --- - - ---- ----------------------------------------_------------------------- --------------------------------------------•---------•---------•-------------- FINAL INSPECTION BY:......tf/__'-- -------------- '__ --------------------- ---- Date----- 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 8-51 Revised W-2100