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APPLICATION FOR SANITATION PERMIT Permit No.,� __/__ _-_ (Complete in Duplicate) .: Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei4de ibed. This application is made in compliance with County Ordinance No. 549. 2( Z ~ 00-1 Z2- ry k JOB ADDRESS AND LOCATION...._!-- " -- ---- - Owner's Name. -- --•---- / Phone Address-------� ---•------ -•------------------------------------------ Contractor's Name------- -- --------- - ---------------------------------------------------------------------------------------------- ----------------- Phone----------------------------------- i Installation will serve: Residen ❑ Apartment House ❑ Commercial ❑ Trail e t Motel E] Other Number of living units: ___�__ Number of bedrooms _Q7__ Number of fka_/,__ ae _____.._.___1_ '__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe [I Hardpan ❑ �1 Previous Application Made: Yes : No New Construction: Yes No ❑ ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: .. Distance from nearest well_'/_Q 9.7_Distan f m foun �'n______ _______ _-Materi No. of compartments—_21- ______________Size_ c _�_!1 ___Liquid depth----------- ---------Capacity__ t Disposal Field: Distance from nearest�eli_�ld_ _-Distance from foundation_ _// �'" Distance to nearest lot li�`___�_______ P---- ------ Number m lines__________ Length of each line____"' ? Width of trench.._.3.6_ ---------------- Type of filter material__.�1 -Depth of filter material------- length------S_Z)------------------------- Seepage ___________ ___Seepage Pit: Distance to nearest well----------------------Distance from foundation----.--------.......Distance to nearest lot line----------------- El Number of pits----------------------Lining material----------------•------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material------._.---------------------____• �� El Size: Diameter-------------------------- -----------Depth------------------------------------------------ :-----Liquid Capacity- _ - 9_s ---;- ---- -.------- em Privy: Distance from nearest well _______________________________________________Distance from nearest building._..-------------------------------------- El -______________ _ ___.___._.❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling -------------------- q I Remodeling and/yr repairing (describe):_ __ �� ---__ _____________ �' _ I I ir�a__ Jx _1- c - ---- --- -- - --- -- /J �Z Gt— "I f -AFI as ep i a di a ia # irta &erwith an Joaquin County ordinances, Sfafejows, and rules and regulations of the San uin Local Hea th Dist cte i (Signed] ------ - - ---- ---� -----------(Owner and/or Contractor) B (Title)_ ,a (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------t--------- ----------------------------------- DATE-------------- REVIEWEDBY --------.. ---- ---- --- --- -----f--- —— - --------------------------------- DATE -- ---- -----_---•------------------ BUILDING PERMIT ISSUEDI DATE - '---- --------------- -------------------- ------------------------------------- -------------------------- Alterations and/or recommendations-------------- -- ------------------------------------------------------------------------------------------•-- ------------------------------------------------- ------------------------ -------------------------------------------•--------------- --------------- ----------------------------------------------------- •------------- ----------------------------------- -----------•---•-__-- -------------------------- --------------------------------------------- ---------------------------------------------------------------------- ----- --•----------------------------------------------------------- -------------------------------------------------------------------- -------- 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 10-52 Revised W-2100