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APPLICATION FOR SANITATION PERMIT Permit No. er•o___7____.. (Complete in Duplicate) 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 li_-- ------------- ...... t l� Owner's .. Name_ -=.. �-- = '"---------- Phone-- � - F - Address_. S " ----------- - ��-- ----- -�-�------ I Contractor's Name--- lx' �� Phone7 Installation will serve: Residence d Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: --- Number of bedrooms _ .K9_ -- Number of baths __l_-- Lot size ----�`a---------- - ----------------- Water Supply: Public system ❑ Community system ❑ PrivateV Depth to Water Table-.44t ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay Loam p Clay ❑ Adobeg Hardpan E❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes ❑ No� � t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: �Y Distance from nearest well_________________Distance from foundation--------------------Material------------___---__________-_--_______:-_______- ;e► .w No. of compartments--------------------------Size------------------------------- Liquid depth----------r----------- Capacity Disposal Field: Distance from nearest well---- from foundation-----!___.____Distance to nearest lot line---Ap_____.__ 4 v Number of lines---!-------/ Length of each line------I,,?r,?---------------Width of trench_____q_y-'�_ Type ,of filter mate#ial__A�___AA,___Depth of filter material___.I�___'_�____Total length--------//�__R____..________________ Seepage Pit: Distance to nearest well------.,--------------Distance from foundation--------------------Distance to nearest lot line_-_______________ 1 ❑ Number of pits------t---------------Lining material-------------------_---Size: Diameter-----------------------.Dopth-_----------------_-------------- Cesspool: Distance from nearest well----------------- from foundation_ __:__.Lining material-----__________-__________-___.______- ❑ Size: Diameter-------------------------------- ----Depth-----.----------------------------------------------Liquid Capacity------------------------ g a Privy: Distance from"nearest well------------------------- __ Distance from nearest building ___________________________________ ❑ Distance to nearest lot line = --------------------------- r � . Remodeling and/or repairing (describe):____ __._ ____ter_ __ _ _: ------------------------ f ---------------------------•----------------------------- ------------------------------------------------------------------- -----------------------------------------------------------•--------------------------------- ----------------------------------------•----(--•-------------------------------------------------------------•------------------------------------------------- -----•------------------ .:r n. --------------------------------------------------------1-1------------------------------------------------------------------- ----------------------------------------------- ----------------------------------- ' 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 the San Joaquin Local Health District. ,�` f �i. ��'++.---+ ---------- ------------------------------- - (Signed)-- ---p--� --z----• -- -----�----------------- -- ------ --- - - - (Owner and/or Contractor) BY• -----------------------------------------------------------------(Title)- - efa 4 (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 r APPLICATION ACCEPTED BY -------- ------------------------- -------------- DATE------------------------------ ---------------------------- REVI EWED BY---------------------------- - - - - - -------------- DATE-- --- DATE__ - BUILDING PERMIT ISSUED ---- ----r"-a - -- --- - - - : - ----- -- Alterationsand/or recommendations-------------- ---=------------------------------------------------------------------------------•--•------------------------------------------------------ -----------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------•-=•--- -------------- ---------- ----------------------------------------------------------------- ------------------------------------------------------- ------------------------------------------------------------------ 3 [ x FINAL INSPECTION BY---------- _- _ Dat - _ - _ - _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street !300 West Oak Street 132 Sycamore Street 814 North "C" $t 1.ree+ Stockton, California Lodi, California Manteca, California Tracy, California' ES-9-2M $-51 Revised W-2100