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it'Nrm APPLICATION FOR SANITATION PERMIT P e o. . .��,��__-_ (Complete in Duplicate) S- S-4 ` Date Issued _ __ _-.--__-- A �l. pplica-lion 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---------------------3.3-_"�)---------- F-------- - I h-W-=------------------- Owner's Name---------------------------- ' ---------!-=----------- QY--L -'---------------------- ------ ----- Phone------------------------- Address-------------------------------------------=--------------------- Contractors Name---------------------- t (Y)------------------------------------------------------------------------- Phone---.....----•--------- _..-•------- Installation will serve: Residence x Apartment House ❑ Commercial [] Trailer Court ❑ Motel .0 Other ❑ Number of living units: _...-_-_ Number of bedrooms Number of baths ________ Lot size _______ - ____________________ Water Sup01y: Public system . Community system ❑ Private ❑ Depth to Water Table -------- ft. .Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,1 Hardpan ❑ Previous Application Made: Yes ❑ No � New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well----. /O------Distance from foundation-----JP----------Material- __-.__ice"{ - �- r No, of compartments----------I-------------Size-----�X�-'--,�---__._--Liquid depth_--------��-�----__---Capacity------- D`7/�. Dispos Field: Distance from nearest well---_-AD......Distance from foundation------��____f_-Distance to nearest lot line------s___..... [ 1 Number of-lines---------------2;a .- _ - _--Length of each line--_60-`4v_-?p____.Width of trench---------�v--_--------------- ---� s d Type of filter material---- y Depth of filter material....____A----__.__._Total length____________/�L1______________________ � Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___--___._____._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation----_--------- ----.Lining material--------.---------- ----------------- El ____- _________❑ Size: Diameter------------------------- ----------Depth- --------------------------------------------------Liquid Capacity-- -------------------------gals. , Privy: Distance from nearest we]-------------------------------------------------Distance from nearest building._------_.__._____.______--------__---._. ❑ Distance to nearest lot line--------------------------------------------- - -•---------------------------------------------------------------- ------•-------------------- _ Remodelingand/or repairing (doscribe---------------------- -------------------------------------------------------------------------------------------------------------------------------•--- ------------------------------------------------•------------------------=------------• ----------- -- ----------------------------------------------------------------------------------------------------------------- ----------------------- --------- ----------------------•----------- ---------------------------------•-•-------•-------------------------------------------------------------•---••----------------------------------- . ----------------------------------------- ----- ---------- ---------- ---------- ----------•--- --------•-------------------------------------------------------....-------------------------------- ' I hereby certifjr I hay ared plication and that the work will be done in accordance with San Joaquin County ordinan es +61aws nd 11 and u ions of the San Joaquin Local Health District. '1 (Signed)------ ---- ------ ------------�-------- -----------------------------------------------------------------------(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------ -- - ------------ REVIEWED BY --------------------- -------- ------------------------------------- DATE------------------ BUILDING PERMIT ISSUED-------------------------------------------------- ---------------------------------- --------------. DATE---------------•-------------------------------------------•- JJJ Alterations and/or recommendations------------------------------------------------------------------------------------------------------------ --------------------------------------------------- ---------------------------------------------------------------------------------------------- --------------------------------------------- -----------------------------•------------- ------------------------------------------------------------------------------------ ------------------------------------------ —// —' / . FINAL INSPECTION BY-------------------�- ----- �_ ------------ADate - ---------- - ----- 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 E5-4--•2M Revised W-2100