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APPLICATION FOR SANITATION PERMIT Permit.No. ._.31 �G 9 r,, 4 (Complete in,Duplicate) Date Issued Application is �6?—M=ade th San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compli nce with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------- -- --- -, ------�--r----' ' _j--------------------------------------------- Owner's Name------------------- Phone ------------------ Address ---------- Address----------------------------�- •- `— - ------ -------• ----------- Contractor's Name-------- .. '� �fPhone - 00 Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ w Number of living units: ________ Number of bedrooms -------- Number of Baths _______ Lot size ______--___________________________________________________ Water Supply: Public system ❑ Community system E] Private E] Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand Construction: vel E] Sandy Loam L] Loam ❑ Clay ❑ Adobe ardpan E❑ Previous Application Made: Yes E] No Nw Yes 40<1 ❑� TYPE OF INSTALLATION' AND SPECIFICATIONS: - (No septic tank or cesspool permitted-if public sewer is available within 200 feet.) Septic Tant. Disfance istance from nearest well-----------------Distance from foundation----_-----------____Material---------------------------------------______-_. o. of com artments--------------------------Size..-----------------------------_Liquid depth--------------------------Caacit Disposal Fifrom nearest well------------------Distance from foundation--------------------Distance to nearest lot line______________-__ umber of lines---------------------------------:-Length of each line------------------------------Width of french-----:---_---------.--------------- -� ype of filter material______________________ _ epth of filter material________________,__.___Total length_____._.________-_..-__________.__ _t-__ Seepa e Pi Distance to nearest weft ____.Distance from €oundation___________________.Dis n e to nearest lot I' e_�___ _ _____ w Number of pits-, _._!___Lining material_______-_____________Size: Diameter------ j�_.-___.Depth s a- �__________._ rl Cesspool: Distance from nearest well-----.-----------Distance from foundation____._-_-_______.Lining material-------------- ___________________- Y r❑ . Size:;Diameter--------------------------------------Depth-------_ - - - -- _- ---------------_Liquid Capacity.Y- ----------•------------gals. Privy: Distance from nearest well________________________________________ ___Distance from nearest building__-__-______________________________.__-._ 0 Distance to nearest lot line-------------------------- --------------- --- -------- -------------------------------------------------- Remodelingand/or repairing describe ' � � Ogg 4 --------------------------------------•----------•-•------------------------------------------------------.-----------------------------------.--------------------------------•------------------------------------------ -----------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------- ------- --------------------------------------•---------------------- ------------------------------------------------------------------------------------------------------------------------•---------------------------- i W I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and rules and regulations of the San oaquin Local Health istricf. 1 (Signed) ---- '-`----- ---?�,40- �� (Owne nd/or onfracfor] b_ BY:-------- ------ ------ -- ----- - ---------- --------------------------------------------------------------(Title)------- R (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT IIS! ONLY APPLICATION ACCEPTED BY--- -` I Z'�'�' � DATE �� lh� 1. rREVIEWED BY--------------------------------------------- ------------------------------------------=------------------------------------- DATE-------------------:-------------- - --- ------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------- --------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendai'ions.-_-------------- ------------ ------- ------------------------- --------------------------------------------------------------------------------------------- F --------------------------------------------------------------------------------------------------------------------------------- ---------------------------- --------------------------------------------------------------- ------------------------------------------ -------------------------- ------------------------------- ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------ --------7----------------------------------------------------------- FINAL INSPECTION SY _-_.-, __ -'-- Dae-- - - = ---------------------------- 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 ES--9--2M 8-5! Revised W-2100