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5 _____ APPLICATION FOR SANITATION 'PERMIT Permit No. ___ ` (Complete in Duplicate] __ r Y Date Issued _----!_'------------ Applica+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 �ATION_ � ` �=t/ �,; ..._�.' , j ' y Owner's Name------ r Phone._ � ! � I � � Address---------- - S"�_o .. `,.._ ----------•---------------------- ----------------- ----- " l G -••- 2L 6 Contractor's Name rf f ` - ------------- IPhone__ --- -_a... Installation will serve: Residence [Apartment House ❑ Commercial 0 Tra ler Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _, _ Numbe Fof�baths - ------ L ot size ------ ---xz_4 D--•------------------------ Water -------------••---••-Water Supply: Public system Community system ❑ Private ❑I Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E3--Hardpan ❑ Previous Application Made: Yes ❑ No LR' i New Construction: Yes �1`o 0 , TYPE OF INSTALLATION AND SPECIFICATION'S: ,,....--� j ( ose tic tankrspolp tted�if;public sewer'is availa d within 200.feet.) e ti dati Material------------------------------------------------- st ceroneares -- IIo No. of-com artmens-- -------- - --------- Liquid eph---------- ---------------Capacity-----------------------L�/ 1 t,] Disposal Field: Distance from s nearest'well._.__oe_______--Di tm ante from foundation___40. _ _ _... _.Distance to nearest lot line_ �-_______ ❑� Number of lines--------,�. Length offYfi t line_______ -------.,Width of french__-__ - _��-.__.- Type of filter 5�-_." .De material:__�C�-------_Total length------`rd--------------------------- �}1 Sepage 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 rearest well------------------------------------------------- from nearest building_--__.-_-..__.____________________._._. ❑ Distance to nearest lot line.------ ---------------- --------------------------------------------------------------------------------------------------- r Y Remodelingand/or repairing (describe):---------------------------------------------------------------------------------------------------------.--_......------------------------------- -------------------------------------------------•--------------------------------••---------------------------------•--------------------------------------------------------------------------------- ----- - -------------------•----------------------------------------------------------------------------------------...----------•------- ----------------------------- -------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, fState laws, land rules and regulations of the San Joaquin Local Health District. (Signed)_---- ------------f---------------------------------------------•--------------------------------- ---------------- ---(Ow er and/or Contractor] By:........... -------- - ---------- ---------------------(Title) ------------------------".�---a'�-- (Piot 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` ---------------------------------------------------- _REVIREVIEWED EWED BY-----------------------------? p----------------- --------------------------------------------------------- DATE =t;; '-- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------�-----------------------•-----------•--------- �A}-lterations"and/orarecommendations-------------------------- --------------• ._------------------------------- 4 i -----------• ----- ----------------------------- -------------•--•---•----,- t- - - --------------------------------------------D--a--t--e---------- --------------------------.._. FINAL INSPECTION BY------------------ •-------------------------•--------------- - 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 /