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APPLICATION FOR SANITATION PERMIT Permit No. - -------- (Complete in Duplicate) -- �- , Date Issued __.��-'--� Ai Iication is hereby made to the San Joaquin Local Health District for a permit to con truct and install the work herein described. This application is made in compliance with County Ordinancce�I No. 549. 1CW/_/s JOB ADDRESS AND LOCATION_ _Q_ _ � - 7i,K� 6'4_ Owner's Name - ri � -------------------------------------- ------- Phone------------'`.----fref Address-------------------------------------- --- -Zll ------- --- Contractor's Name-------------•---------- - -------------------------------------------------------------------. Phone---3?=,OV_0�7-------- Installation will serve: Residence ❑ Apartment House ❑ Commercial j2rTrailer Court [] Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths ._.f_-. Lot size __-_______________________ Water Supply: Public system % Community system E] Private [3 Depth to Water Table 4®ft. N Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe X Hardpan ❑� Previous Application Made: Ye Not New Construction: Yes J4,No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS! (No septic tank or cesspool permitted if iip��ublic sewer is available within 200 feet.) Septic Tank: Distance from nearest we1_14-MEfrom foundation-_--`--------Material_�e_ --- - ----_---. No. of compartments__1__________________Size_4_f9A'x_j3;.___Liquid depth__��-`.'_______----- Capacity..' d _ Disposal Field: Distance from nearest wellA-4--At,1__Distance from foundation------�jiCf------Distance to nearest lot line___._ ❑ Number of lines--------1._------------_________Length of'each-line___`__ -" «-.Width of trench:�__t: +� Type or filter materiaL_jDepth of filter material___._ -----Total len th__ _______________ Se a Pit: Distance to nearest well-.!`.!'_Q_+ +E------Distance from foundaticn_ --•___•-.-__.Distance to nearestllot line___-_-_-_._ Number of pits j/_.__.___________Lining matenal �1 Size: Diameter__...,3.!'_______Depth#_ _„C`_ _____ ____ Cesspool: Distance from nearest well__ ___________Distance from foundation--------------------Lining material__.____ .._._____._.____-____________ jF Size: Diametery- ----------t- - Depth I' : Liquid Capacity gals. Privy: i Distance from rearest well_____________________�___._____..,___,________._Distance from nearest building__ __ _--_---- a __. .._ w ... ❑ � Distance to nearest lot�line`----------------------------------------------------------- -YL " � ------------- -----------Remodeling and/or repairing (describe): -----...----�----------'�-----r --------------.--------- ------------ i ----------------------- -----•------------------------------------------------`---`-------------...------------------------------------------------------------------------------------- I hcertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws, and rules an regulation/s of the San Joaquin Local Health District. C� (Signed)-_- ( --- ( Contractor) ---------------------------------- ----- - -- -------------------------------- By: ----------------------------T By-----------------------------_---•----•--------� ------------ --- -- ---------�� (Title)- .l�z �-Ey--- ---------- ------- (Plot plan, showing size of lot, location ofsystem in re on o wells,'buildings,/etc., can be pln reverse side). FOR DEPARTMENT USE ONLY r� APPLICATION ACCEPTED BY---- ------- ------------------------------------------------------- DATE--------[ ... ----- ----- - - REVIEWEDBY--------------------------- ---. . ---- - ------------------------------------------------------------ DATE------------I-- -------- BUILDINGPERMIT ISSUED------------- ------------------------------------------------ --------- ••------=---------------- DATE------------------------------------------------------------ Alterations and/or recommendations:--.------------------------------ -------------------------------•---•----•---------------------------•-----•-------------•------------- I. --------------------------•--------------------•---------------------------- -------------------------------------------------------------------------•-------------------------------- -------------------------- ---------- ------------------- -- ----------------- y--_------------------------------••----------------------------- •----------------- ---- --------------------------------------------- ---------- ------ -'----------------------------•-------------- --------------------------------------- ----------------------------------------------- i Y FINAL INSPECTION BY: e _ Date----------------------------------------------------- -------------------------- SAN -------------- ------- 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 10-52 Revised W-2100