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APPLICATION FOR SANITATION PERMIT Permit No __ (Complete in Duplicate) Date Issued (� it to construct and install the work herein described. District for a permit Health Distr+c Applica{ion is hereby made to the San Joaquin Local p This application is made in compliance with County Ordinance No. 49. JOB ADDRESS AND LOCAT 4N- ----------- - ----------------- Q - - - ---------------------- Owners Name-------------------- .----- ----- ----------- -----...: Phone _ f P Address---------------------- .. - ---- -•- - ------------------------------------ 0- ----•------ .... _.._--- ---••--- ----- V7 --1 -- I Contractor's Name-------- -- -- ------------------------------------ Phone Installation will serve: Residence A artmenf House ❑ Commercial ❑ Trailer Court ❑///'Motel ❑ Other ❑ .___. Number of bedrooms Number of baths A� Lot size _!_.7-- -Y-�".1--1-•--------------------------- � Number of living units: _ - - - Water Supply: Public system '❑"i Community system ❑ 'Private Depth to Water Table':------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam [I Clay ❑ Adobe ardpan E] ; `- 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 k: Distance from no well7_ ___- --Distance from foundation___ : ___ f�latena_____.____" p No. of compartments------I--------------Size-, y0-X- ------Liquid depth___'_ J-------------=Capacity---4$-------- ----•- It p Distance from foundation_____________ ___Distance fo nearest lot lin ................. -- -1--r- 0_".��.Width of french---fir ------- -- Dis osa field: Distance from nearest well_ _ _._ _ er of lines-3 Type e or filter material_ Length of each line_______ 1 yp r ' --__ Depfh,of filter material_--� __`---____Total length_____!_-f-_________________-------•;-- Seepage Pit: distance to nearest well_______________ _____Distance from foundation"...___....__..F__.Distance to nearest lot fine__.__------------ �, ❑ Number of pits----------------------Lining materia ------------------ Diameter------------. ____D_epth-=------=--Y_�,:----=_-===-" ' Cesspool: 1 Distance from'-nearest-well- -.' ' well _. =="Distance from fou dation _.__" __.: `_Lining material-_ ------------------------------- 'Liquid --- ----" gals. e: biei' fer- ----- ---- Depth Liquid Capacity-- --------•-------------- a .p,,ti.% t ------- Priv Y Distance rom nearest•well-------------------- ------------- --------------Distance from nearest building---------------------------•------- y ❑ —Distance to nearest lot line------- ----- -------------------------------------------------- ----------------------- x Remodeling and/or repairing (describe):----------------------------------- -------••---------------_-------------•-------------- ------•-----------•-----•-•- ---------------------------------------------- ?- ;;k -------_-------------- -•--••-----•----- -----------------•- ------------•-------------••-•-----------------•------•--•---------------•--------•-••----------------- _ .,, +� --- -- - -- - - - ------ ...--- ------ ------ ----- -- _ I;hereby certify fhat I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, Sta a law rules a d egulations oftheSan Joaquin Local Health District. y 1 (Signed) - ------ -- --------------------------••------------------ ---(Owner and�or Contractor) ------- r--------------- ---- --- -- -- sy:------------------------------------•---------- (Title)---------------------------•----------------- (Plot plan,.showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F E' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------- '" ----------- DATE REVIEWED BY ===---=-------------- - -- . _.�r{ MIT ISSUED = -- ----------------------• DATE------------------------- . BUILDING PER - --------------------------------- Alterations and/or recommendations: e -- -------•--------------------•--------•------ 1 ----------------------4-- ------------------ -------------------- •------ f_ _ e __ _______________"_.___._ ___.._____.___._._.____ __. -_ .-.-_______ � ________........____________ __________________ � ___.._ ______i___.__"" _" 1 _ __ _... --•-------•-------------" -----—-——-----____. ---------__---------------_-------— ------------•--------------•---_-----——--------------•—------" --------------------------------- --------------- ________•____ FINAL .INSPECTION-BY:.�'-- `-- Date_. -=-�-- --- r ---•-------------------- 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 FS-9-2M I ..Revised W-2100