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1 F APPLICATION FOR SANITATION PERMIT Permit No. _ -Q_ .� {Complete in Duplicate) A Date Issued Aie/ - Application is hereby m de 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__ .. a--3 o_ 41e b e—/"' Owner's Name --fp --------------------------------- ------------------- -------- ---•- ^------ - ---- ---- ----------- --- ----------------- Phone-----------------------------•----- Address-.............. - --------------- Contractor's Name = - v�'► Uee �1f ------------------ ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ---�I—Number of baths -------- Lot size _______________ S Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table -------- ft. Characterof soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ek Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No� TYPE OF INSTALLATION AND 5PEC1FICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation------------------- Material ❑ No. of compartments------------ -------------Size--------------------------------Liquid depth------- ------------- ----Capacity--- - - --------------- Disposal Field: Distance from nearest well---------------._Distance from foundation----_---------------Distance to nearest lot line___-__________--{�� ❑ Number or lines----------------------------------Length of each line------------------------------Width of trench 1N Type of filter material_________________________Depth of filter material ___.------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest loft line El 1e� Number of pits--- -------------------Lining material-----------------------Size: Diameter------------------__Depth--------------------- ------_----- { 1, Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material------------------------------------- El Size: Diameter------------------------------------- Depth---------------------------------------------------Liquid Capacity gals. -- -------------- Privy: Distance from nearest well--------- S;r---- Distance from nearest building-______-_--______ Distance to nearest lot line �__ ----------------------------------------------------------- ----------- ------------------- I Remodelin and/or repairing (des�ribe)--------- -------- --- J-- pL. �D7 � --- ------------------------------------------------ ------------- -- r------------------- ------------- ----° -------------- - --------------•-----•-------•--------------------------•----•----•-----------•-------------------------•------••---------------•----•--------------------------------------------------------------------- I ------------------------------------ ---------------------------------------------------I-------•--------------.----------------------------------------------------------- ------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. - (Signed) �---- --- ------• - {Si g )-__ - � ----- - -- --------------------------------------------------- --------------------(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------------- DATE____- ---__ -� BY REVIEWED BUILDING PERMIT ISSUED-- ------------------------ --- - ------------------------------------------------------ ---------------- DATE------- ------------ -------- -- --- --------------------------------------------------------- ------ DATE_------------------- Alterations and/or recommendations__________________________________ _ -------- •----------------------------------------------------------------------------•-----------------•---------- --------------------------•-------------- w. ------------ ----------------------------------------------------- FINAL INSPECTION BY:------------------- ------------ Date---- ------------- SAN -----------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 16-52 Revised W-2100