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01A KATION FOR SANITATION PERMIT Permit No. __ __ __ _-. (Complete in Duplicate) J'+D 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 LOCATION___* jj--a�o-)s .__�.__.-�� ------------------------------------------------------ ------------------------------- Owner's Name-------------- -----------------X11 � ,_ '•----- , %?. '�------ ' ------------------- Phone- Address.--------------------- hone Address---------------------- - -,>x ----- Contractor's Name---------------------21, � t--------------------------. �.w. �.f Phone - 4E Installation will serve: Residence ❑ Apartment House ❑ Commerciale Trailer Court ❑ Motel ❑ Other E]Number of living units: ________ Number of bedrooms -------- Number of`�6aths _/___ Lot size �_ ____- _+� !.,` - Water Supply: Public system ur, Community system ❑ Private ❑ Depth to Water Table �Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe o_ Hardpan ❑ Previous Application Made: Yes ❑ 'No'[�j New Construction: Yes/9,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 well______________Distance,,f�m,fo �dation_ :_________-_-_.-_.Materialr_________________-_�__ _..____-_._ No. of compartments-----�----------------Size_�__r_ ------•--- ---------Liquid depth-_`�__ec�___------------Capacity-- t7D---------- Disposal wield: Distance from nearest well-----------------Distance fr n foundation--------------------Distance to nearest lot line_________ ❑ Number of lines-----------------------------------Length of each line-----------------------.-----.Width of trench------------------------------- Type of filter material-------------_-----------Depth of filter material_,_-------------------Total length--------------------------_____.---------- Seepage Pit:. Distance to nearest well-_,r!kr --'_-Distance from fo�ndation/!,.___....Distance to nearest lot line__f" CA Number of pits_____-_1-__--____.__Lining material_ T* ---Size: Diameter__a?_?-----_______.Depth___!0_!;7------_----------- Cesspool: Distance .from nearest well-----------------Distance from foundation--------------------Lining material-_-_______--____---___-.____________.. V1 ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------------•--gals Privy: Distance from nearest well------------------------------------------------- from nearest building----------.__-__-__--_------------------ ❑ Distance-to nearest lot line------------------------------------------------------------------------------------------------------------------------------- Remodeling -and/or repairing (describe}:---------'---_ -.PECr� _ 1 t --------------------------------------------- 1 ---------------------•------------------------------------------------------------------.-------------------------------------------------------------------------- ----------------------------------------------------- --------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------.------------=------------------------------ 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 ' an JoaquiA Local Health District. (Signed) ----7------------------------------ -----------------{Owner and/or Contrac�r] 1 -------- Title ---------------------------------------------------------------- (Plot plan, show' g size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -------- ------------------=--------------------------------------------------- DATES-- .� REVIEWEDBY---------- ------------------- ------------------------------------------ ------------------------------- ------ DATE-- - ---------------------------------------------- I BUILDING PERMIT ISSUED------------- r------------------------------------------------------------------------------------ DATE----- Alterations and/or recommendations:----------------------- --------------------------------------------------------------------------------------------------------------------------F . ------------------------------------------------------------------------------------ ----------------- -- --------------------------------------------------- ---------------------------------------------------------------- .----- ----------------------- -------- ----- ---------------------------=------- FINAL INSPECTION BY: - '� 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 Manteca, California Tracy, California 4 E5--9--2M 8-51 Revised W-2100 • .a f.