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PLA_ S APPLICATION FOR SANITATION PERMIT Permit No. ____. ............... (Complete in Duplicate) �� 3 S Eo w[ Date Issued ________---___-------- Applicaa-ion is hereby made to the San Joaquin Local Health Dist ricf for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. J JOB ADDRESS AND ��O]CATION.. _ ----- tl.C. ----. - -- Sit-- �_5= ¢_ e - -___------�-' �F� Owner's Name--------(/[/tl./--o�rral+r--..._ 1--.-- t#•- G- --------- -- Phone--------------------- •- •- •- # -. . /�/� / R Address ',7 Cl..._l r f --------------- ---Co ---�'!•Y-)------•------•---•------------------------------------ Contractor's ntractor's Name---------------------•-------------------------------------------------------------------------- -------------------------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other .ter r Number of living units: __/__ Number of bedrooms _;!�-. Number o baths __ Lot size _ _ ___X_._344 6------------------------ Water Supply: Public system ElCommunity system Elvate Priepfh t Water Table _._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No FX�New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool'pe-rmitted if public sewer: is�available within 200 feet.} Septic Tank: + Distance from nearest well!_t .__Y.'--Distance from ® . , _ found�tionm No. of compartments.......�L----- .....Size__�V3_X>-----Liquid depth_-. �_�-----------.,__Capacity_____ Disposal Field: , Distance from nearest-well.7iO__.._-_.__Distance from foundation 1-2' _.-..Distance to nearest lot line._'S___'?'"u•'11- ® Number of lines___._____ _2-- Length of each line------ jf__._.Width of french----- _ --------------- -Type of filter material_-- Depth of filter material----/_?------._.Total length_______ _ --_____________._ 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 .-_-__-____.-__.___.________________ ❑ Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity---------------------------gals. Privy: Distance.from nearest well---------------------------------------_---------Distance from nearest building------------:_________________________--- ❑ Distance to nearest lot line-------- -------------------"------------------------------------------ Remodelingand/or repairing (describe)------------------- ------------------ - -------------------------•--------------------••---------------•------------------------------------------------- ------------------•----------•----------------------------------------------------------------------------•---•--- -----------------------•------------N -------------------------------- ---- ---------------••---------------------------------------------------•-----------------------•-•---------•-•-----•------•--------------------•------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County (a y ordinances, State laws, a d rules and re ulations of e San Joaquin Local Health District. - g JJJ�� q . (Signed( {Owner and/or Contractor) $ -=`----------------------------------=--------------- ------------ (Ti#le(- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR •EPARTMENT-USE ONLrl1' APPLICATION ACCEPTED BY ---------------- DATE----- _,• -`_ ---------------------- REVIEWEDBY------------------------- --------------------------- ----------------------------------------------------------------._._._ DATE------------- -- ----------------------------------------- BUILDINGPERMIT ISSUED--------------- ------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:--------------------------------- -----------------------•----------------------...._..._------------------------------------------------------.--_--._----- --------------------------•----------••-------------- --------------------------------------------------------------------------------------------------------------_....---•-------------••-------------------------------- ----------------------------------------•------------------------------------------------------------ -------- --------------- ----- ------ ------------ --------------------------------------- "------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:. ------------------------- --'._= Date.-. � l Vv 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 145445 ATWODO 12-54