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ttV// APPLICATION FOR SANITATION PERMIT Permit No. ..73..3 e.... in Duplicate) W(41 (Complete P 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 O Bina o. 549. JOB ADDRESS D LOCATION...----- �-. .. _ ., ._. ._.__... sT -----------------•---•---•---------------------------------------------------------------- Owner's Nam ------------ Phone------------ ------------- ------------------------------ Address--------- ----------------- "J- - Contractor's Name---- ---- -- ------- - - ----------------------•-------------------------------- --------- Phone.------- -------------------------- Installaion will serve: Residence Apartment House ❑ Commercial ❑ Trainer Court ❑ Motgl ❑ Other} ❑ Number of living units: ...... umber of bedrooms ..Z. Number of baths ..L_ Lot size .� .--x._- (,!__l__..._....-.-.---. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel El Sandy Loam [_-] Clay Loam E] Clay ❑ Adobe [Hardpan L]Previous Application Made: Yes E] No New Construction: Yes []1No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public se er is available within 200 feet.) Septic nk: Distance from nearest well..-- __ istancP fro four�J? ion----�.Q.---._ Materi Iy-....----- --- ------ Na. of compartments....-- - -----____-- ize _X_ -•---Liquid de th---------------------------Capacity..- _- - Dispos Field: Distance from nearest we 4f X- Distance from foundation---.— Distance to nearest lot li -- Number o; lines.-.-__---- ..fv___...___ _Length of each line-------- - .r Width of trench....-..Z Type of filter materil�1/a�-c/K.la p i g t ....-- e th of filter material- -..f�--__._---Total length.............1_��----------------- Seepage Pit: Distance to nearest well......................Distance from foundation----_-------------Distance to nearest lot line.........-_._._. g s ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----.------------------Depth--------------------------------- N Cesspool: Distance from nearest well-----------------Distance from foundation... -------------Lining material--.--......-----------_--.__......._. ❑ Size: Diameter--------------------------------- ----Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------...._.--_...-. ❑ Distance to nearest lot line----------------------------------------------------------------------- ------------------------------------------------------- Remodeling and/of repairing (describe):------------------------------------------------------------------------------------------------- ---------------•------------------ -------------------------------------•--------------•-----•--------------•------------------------------------------•-------•-- ----------- -------------------------------------•--------------------------------- ----- ---------- --------------------- --------------------------------------------------------•- ----------------------------------••---•--------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules ar� regulation of the San Joaquin Local Health District. . (Signed) �V_ ------------ --------------------------------------------------------- --------{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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------- Y.... ......... .. --- DATE.r -------..----...-- REVIEWED BY-------------- DATE -e BUILDING PERMIT ISSUED----------- --------------------------------------------------------.- DATE --- -L------------ --------------------------------- Alterations and/or recommendations:------------•------------------------------------------------------------------------------------------•--• �------------------------•---------- ----. - ------------------------- ----------------------------------------------- --------------------------------------------------------------------------------------------------------- -------------------------------- FINAL INSPECTION BY:. � iJ- � - ------------------------------ 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 Manteci, California Tracy, California • ES-9-2M 10-52 Revised W-2100 I