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t , 11A .'J, APPLICATION FOR SANITATION PERMIT ,a• Permit No. ©__ ____ (Complete in Duplicate) 9 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 LO . TION-----4_z�------? ------ --- --------------------------------------- ---------------------------- Owner's Name------ - e ^- / Phone . `c .�r �-yam,. ' .1 Address----------------------- •-- ------------------- Contractor's Name------ �� >� (i/—----------------- Phone-V - Installation will serve: Residence 0"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- umber of bedrooms :,-__ Number of baths J--- r y fLot size Tp !i' `" f� Water Supply: Public system [i 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 6XHrdpan ❑ Previous Application Made: Yes ❑ No ❑ Now Construction: Yes ❑ 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 we'I:,&/i 4: Distance from foundation)-6__ Material-( __ ____- No. of compartments----------------------Size-,_- ------'Liquid depth----'�---------------Capacity_i�'�d------- Disposal Field- Distance from nearest ll�&�_ Distance from foundation___/!�_'-------Distance to nearest lot line___-_ - Number of lines_______. Length of each Fine_ -� _ '. Width of trench__.,. _ __________________ Type of filter material _,1_t_�_- -, Depth of filter material___I_V-f f____--Total length------- fir------------------- V 1 Seep e,Pit: Distance to nearest well__ 4_l1_ ,__Distance from foundation__�_ _�_........Distance to nearest lot line_-___ _�_____ Number of pits-----------I--- -----Lining material--�4,.;_ ,��: Diameter------ `�-�{-------Depth---•�--�"-----•--------_---- Cesspool: Distance from nearest well----_------------Distance from foundation--------------------Lining material_____________________________________ ❑ Size: Diameter--------=s-----•----------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. ` Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot dine ' - ' -- ------------------- ____---- - ------------------ r Remodeling and/or repairing (describe):--------- --- ` G'=' -f-` - , . r •--------- -----------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------- ------------------------------ ----------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------•---------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules and regulations of the,San Joaquinlocal Health District. (Signed) �1 y, '• f�. �� --� F = (Own;K and/or Contractor) : -------------------------------------------------------------------------(Title)--- =r _ ------------ (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 APPLICATIONACCEPTED BY ---------------------------------------------- -------------- ----------------- ----------------- DATE�-----------------------------------•------ -------- REVIEWEDBY------------------------------- ----- -------------------------------------------------------- ------------------------ DATE---�--------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------- Alterations and/or recommendations: FINAL INSPECTION BY: __: ;�"tom ---------------------------------- Date ` /- IZ-b---------------------------------- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100