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` y r 30 APPLICATION FOR SANITATION PERMIT Permit leo. . (Complete in Duplicate) - //iy�- Date Issued ---___...". .._ Applicaa-ion 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 LOC ION ---- , -------•-------- ------------------------------ ---------------------- Owner - -V C°.. Owner s Name ---"------------•--------"--------------------------- Phone Contractor's Name________ _ l�'� ' Phone__ Installation will serve: ResidenceApartment House ❑ Commercial ❑ Ti aile'rr Court'❑ Motel ❑ Other ❑ I Number of living units: __.l__ Number of bedrooms _.�4_ Number of baths`_,_:_ Lot.size . �_t__--____________.___-____ � c r _ Water Supply: Public system ❑ Community system ❑ Privateo Depthf to Water Teble;(/e ft. Character of soil to'a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobg Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yess No ❑ ' # 4 TYPE OF INSTALLATION AND SPECIFICATIONS: rk (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest well------------------Distance from foundation---------- ---------Material---------'____________________________F______.-. Not of compartments--------------------------Size-------- �-----------------Liquid depth---------- ---------------Capacity--------------- Disposal •eld: Distance from nearest well_________________Distance from foundation---------- -------- Distance to nearest lot line----------------- Number of lines----------------------------------Length of each line----------------- ---------Width of french--------------------------- /F;�, Type of filter material----------------- -------Depth of filter matErial-------------3------ -Total length--'-----------------_.--------'--------- Seepage t. nDistance to nearest well_____'____.______Distance fpm fo dation__, _____. .Distance to nearest lot Number of pits----/-_______________Lining material _ _ _ ___.Size: Diameter__..,7___- Depth-" Cesspool: Distance from nearest well---------------_Distance from foundation--------------------Lining material-------------------------------------- Size: Diameter---------------------------...........De th____'.__:_______________ __._.._-___Liquid Capacity - __gals. Privy:' Distance from.nearest well-------------------------------------- --Distance from nearest building_'__ ____________...-__:- ❑ Distance to'nearest lot line---------------------------------------------- i s w T.- --- ------------------- x �. Remodeling,and/or repairing (describe) .f._•«_______ (describe): 4fe5 _e_ -_ i.-- __________._______________--_____________-___--___________ ___-___-___-__-.__-____.___________-_______-___________._________r_________-'---_____..___.--___-___________11-1------------ ----- --- ______________- N ------------------------------ --__--.-____-- --------------------------------------------___________._----_..__-..-.____.._-__-.__.--...... ------------.-------------»..--------.---------------------.--..----------------------- _ ----------_________________---------- _----------- ___-----------------------------------------------------------------_......._----------------------------------------------------------------------_------_---------------- � I hereby certify that Fhave prepared this application and that the work will be done in accordance with Sart Joaquin-County ordinances,.St a laws,.and ry es and egulations of the San Joaquin Local Health District. ' t (Signed).-- t �_ _e- -- ------------------------------------------------------------------------------- .... [Owng dor Contractor) By:. ------------- --- ; --------------------------------- {Tale -�r . a - --------------------------- ----------- may . (Plot plan, showing ifze of lot, location of system in relation to wells, buildings, etc., can be par ed an reverse s' e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ --- - -------------------------------------•---------------•-------•--------------- DATE-- a ---- - -- -- - ---- - --- REVIEWED BY---------_`=,, - ------ -------------------------- -------------------------------------- DATE BUILDINGPERMIT'ISSUED------------------------------------------------------------------------------------------------------- DATE--------- ----------=--------------------------------- Alterations'and/or....recommendations:------------------------- -------- ------------------------------------------------------------------------=------------ - -----------=-------------------•-------•--------------------.-.-•-------•------•-----------•------.------•-----•-••-------------------•••--------------------•--•----------------••----------•------------ •----------------- --- --------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- I -----•-----'---------------------- -------------------•----------------------------------------------------------------=---- ----------------------------=---------------------------------------------------- ---------------- --•--------• ----------•--- -------------------------------•-------------------------------------------------------------------------------------------------------------------------•----------------..-..._..--------------- FINAL-INSPECTION`BY:--:��---------------------=--------- Date-- ---------------------------------------------- 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 ; Revised W-2100 »