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APPLICATION FOR SANITATION PERMIT Permit No. .-k ;___. .._ (Complete in Duplicate) Date Issued ____ ffl..S ___ Applica+ion is hereby made to the San JAquin Local Health District for a permit to construct and install the work herein described. Th's application is made in complia c with County Ordinance No. 549. JOB ADDRESS AND L CA, ON � � � 13 (at !{�__ J�t� f Owner's Name-c9_ ----------- ---• -- - ----------- Phone-----------•-------•-- -- v¢ . Addressf# _5 ., -- - -------------•-----•-•----------------•-----------------------------------------------------------• --------------- Contractor's Name__ --- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court (]/ I tel Other ❑ Number of living units: _- _ Number of bedrooms _ ! �f _ ---- Number of __-- -- Lot size -- ---- --- - - --- �-__•---------------•-- Water Supply: Public system k ommunity system ❑ Private ^epth to Water Table ._ ____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑' Clay Loam Clay ElAdobe❑ Hardpan E] Previous Application Made: Yes ❑ No V New Construction: Yes [IO No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet) (� f. / _'" RSI - ptic ank. Distance from nearest we€l-� --�__.__ Distance from foundation____ ___ _ _. a#erial__._.__ Se No. of compartments__________._ __. Size ,r �---- --------------------------------Liquid depth---------- ------------Capacity------ -��------ .� Disposal Field: Distance from nearest well -----Distance from foundatio 26' Distance to nearest I t li � ��f✓ Number of lines__________ ____ ______-- _-Length of each line______ � - Width of french------- Type of filter mater; epth of filter material---- _____Total length______________ _ Q -------_.._ Seepage Pit: Distance to nearest well------------------_---Distance from foundation....................Distance to nearest lot line_____._.__._.-_ ❑ Number of pits----------------------Lining materia;-----------------------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---- - ------••-------•-------------------------------------------------------------- mo¢ liling ond]/or /r]}epairin (descril�, -------------------------------------------------------------------------------•-------------------------------•----•------------------------- -------------------------------------------------------------•------- ----------------------------------------- ---------------------------------------------•-------------------------------------------- --------------- DO I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and relotions of the San Joaquin Local Health District. (Signed)--•-- - F ? -------------------------------------•------------------------------------------------(Owner and/or Contractor) By:----------------........ ----------------------- - 1---------------------------------------------------------------•----(Title)---------------------------•------------------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-! -- --••-------------------- DATE'�„^------------------------------------------------------ REVIEWED BY-------------------------------- - --- DATE__( . BUILDING PERMIT ISSUED...... --- ----- DATE------ .�-____-- Alterations and/or recommendations:----------------------------------------------- ------------------------------------------------------- --------•-------------•----- ----------------------------------------------------------------------------- ---------------------------------------------------------------------• ----••--------------•-------------------------•----------•-------------- -----------------------•• -- ---------------------------------------•--------------- -------------------------------•-•---------------------- ----- ------------------------------.--------------------------------------- --------- r-� ---------------------------- FINAL INSPECTION BY:..- –C— Date..... .=�,-------- SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100