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�p \ vo� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 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. 549. ��? .ti. JOB ADDRESS AND LOCATION •-------�� ---------- ..... :ir------------------------- ----------- ---- ----- Owner's Name •----------•- ------- ------ Phone ,� �f Addresses _ y _' -------- ---- --=' - - Contractor's Name-- ( / ' -�-------------� �-� �!,f---c-_- --------- "- - -•-----------------'----------------- Phone-;-.----•-�---•�-x"71-• `r Installation will serve +Residences'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of liking units: --- Number of bedrooms-- h �� :Number of bat __ Lot size __ U___.--s / � ------------------- \ /- � Water Supply: Public system ❑1 Community system ❑ Private Depth to Water Table_3sft. t Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam-0 Clay Loam ❑ Clay [❑ Adobe—Hardpan [-] t Previous Application Made: Yes ❑ No New Construction: Yew No ❑ 4TYPE OF INSTALLATION AND SPECIFICATIONS: f" 41 ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.] ' Septic Tank: Distance from nearest well--------e--_-Distance from foundation--------------------Material------------------------------------------------- x `N of compartments `�` Size I-$ Liquid depth Capacity--------------------- % Disposal Field.- Distance'from`riearesf ell-----------------Dis ante from foundation--------------------Distance to nearest lot line-------.--------- ❑ Number of lines-- ------------------------------Length of each line-----------------------..----.Width of trench-------•----------------- /J Type of filter,material-------------------------DVfh of filter material------_----___-,,,. _---Total length-------_.-_-----__--------_ Seepage Pit: Distance'to nearest well-___- _ .-------Distance from foundation..-t/a........Distance to nearest lot line-__-. _----_ Number of pits-_-.-- - Lining materiae-_ f_Size: Diameter-_.- .----Depth________ ,; f _ ; Cesspool: Distance from nearest well-----------------Distance from foundation- .-_----.Lining material---------------------_--------_---_- 0 Size: Diameter. - ---------------- ----------Depth----------------------------------------------------Liquid Capacity.---------------------------gals. Privy: Distance from nearest well.-------------------------------------------------Distance from nearest building------------------------------------------ ❑ F Distance to nearest lot line---- ------------------------------------- „------------------- Remodeling ----------- --__Remodeling and/or repairing (descrihe�:_-!, ------------------------•_,-•_ _ -*n r 1 ....... ...... . ... '__T - ---_ _--• - ---------------------'----_ _•_------_- ----- --_------!'-- __ - r ----•- ---•-------_- -•--•• _-- _------------- - • ----------------- f i• ! _ ..i - • -.:•^'-_A------------'�-----------------------------------------'----------•---••------------------------------------------------------------------------------------'---•-----•--------._----------------"_-----.- 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. }� � ----------------------l_{Owner and/or Contractor)(Signed)... -- ---- --------- - ` --------------------------- rr------ -------- ---�^-`'- ----------- s (Plot plan, showing size of lot, loc-a of system in relation to wells, buildings, etc., can bee)-iia d ort reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ------------------------------------------- DATE------------ -------------- REVIEWED ----------. -- 'REVIEWED BY------+------= --------------------- r------------------------------------------' ---------------------------- DATE-------------------------------------- ' BUILDING PERMIT ISSUED------'---------r------------------------------------------------------------------------------------ DATE---------.. --------------•---- Alterations and/or recommendations---------- ---------------------------------------•---•----•----------------------------------}-------- -------------------------------•----•---------------- ---------•---------------------------------------------•--------•- ----------L----------- --------------=-------------------------------------------------------------- ' =----------------•------------•------------•----------------'----------------------------------------------- -------------------------------------------.----------------------•------------------------------------------- •---------------..._..---------...-----_------------------------------- � z -z � FINAL INSPECTION Al-,-ell, BY:------------------ ---------------------------------------- Date----------------------'----------------- ' 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-9-2 Mf ; Revised W-2100 �— --