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p APPLICATION FOR SANITATION PERMIT Permit No.-��--_l__-_ � ` (Complete in Duplicate) - Date Issued 4— -.Z_ -:-- Applica+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. 5`49. JOB ADDRESS AND LOCATION.... .' ► :--------- ---------------------------------------------------------------- Owner's Name , -------------- ----- --••----- ------------------------------------------- Phone------------------------------------ Address------ -------------------------------- -Address------ .. .........N ............. -- --------------------------------------------------------------------------------------------------------------------------------- Contractor's ---------------------------------------------------------------------------------,-/--------------- Contractor's Name-----d ------- ------------------------------------------------------------------------------- Phone . `Fll� �r Installation will serve: Residence ertment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---)___ Number of bedrooms ._r% Number of baths --j---- Lot size -----157 '_-----x-----I__-6_q------------------ Water Supply: Public system .Community system E] Private E] Depth to Water Table 6"-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobelardpan ❑ Previous Appiication Made: Yes ❑ No w Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200'feet.) V Septic : ------------------------------------------------ TackDistance from nearest well-----------------Distance from foundation-----___--_--------.Material . No. of compartments-------------------------- --pSize--------------------------------Liquid dept,------------- ------------Capacity------------------�... Disposal Field: - Distance from nearest well_l� istance from foundation-_--_L-= .--.--Distance to nearest lot line-16---.._-. I N_ Number of lines---------- ----- - Length of each line-------4-0_--4----.----:Width of _---__----- Type of filter material--�- .._- --- -Depth of filter material----._-t�_ `_f_-To#al length__----- -_`�----------------------- �• .____Distance from foundation--- r ,♦ Seep ge Pit:.- Distance to nearest well-._ _- .. --�_...__.Dcstance to nearest lot line---)-._.--`--_ Number of - pits------ --------------Lining material--- -.Size: Diameter-_ j---------.----Dept h------, 4----- - ------------- Cesspool: Distance from nearest well-----------------:Distance from foundation------------------- Lining material------_-----_------.---------_-_-----. I. ❑ Size: Diameter--------r--------- -------- ---- ----Depth----------------------------------------------------Liquid Capacity- --------------------------gals. Privy: P-Disfance from nearest well-----------------------------------.---------Distance from nearest building--------_-._-.----_- ---------------------- ❑ Distance to nearest lot line----------------------------------------------------------------- ---------------------------------------------------------------------- Remodeling and/or 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ... .. Contractor) -- -- 3y:-------- ----------------------------------------------(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 I APPLICATION ACCEPTED BY-------------------------------- - ------- -- DATE - - - --------------------------- REVIEWED BY----------------------•------------------------------------------------------- ---- ----------_.---- ---- - . DATE---- --0- PERMITISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------- -- Alterations and/or recommendations:----------------- ---------------------------------------------------------------•-•-----------•------------------------••---------------------- ------------------------------•----•------------------------------------------------------.-.-..---------------------------------------------------........................................................................ -------------------------------------- --------------------------------------------------------------------------------------------------------------------- ----•----------------------------------------------- -----------------------------•---------------------------------------- -------------------------- ------- ---- -------------------------------------------------------------------------------------------•------•----------- � � d—2 S c FINALINSPECTION-BY:---------------------- -------- --------------- Date------------------------------------------ .�--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100