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(� I pt APPLICATION FOR SANITATION PERMIT Permit NVeindescribed. omplete in Duplicate) Date Issu ___7Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION....... e.�___ a- `______ Owner's Name 4 .---- - --- ------ Phone-.1 � 1l�y"7 Address/5---127-• .. ._--•; -- '+rl -- -------------------- -•---•. - ,y one -•------------------------i Contractor's Name__--- _ �� Rr--•--------------- Phone_ :__!'1�___ - -- - - -- -------------------- Installation will serve: Residence ff"A"partment.House ❑ Commercial E Trailer Court ❑ Motel ❑ Other ❑ Number of,living units: J___ Number of bedrooms -a2-_ Number of baths __/._ Lot size �Q-... -,l.Q___4±!______________________ Water Supply: Public system Community system,F1 Private ❑ Depth to Water Table Qft. Character of soil to a depth of.3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan Previous Application Made: Yes ❑ No [ New Construction: Yes []rNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) epti Tank: Distance from nearest well-----------------Distance from foundation--------------------Material---------------------:___ ---------------- No. of compartments--------------------------Size.................................Liquid depth--------------------------Capacity_ :_ -Dispospl FF, d: Distance from nearest well-_------------ -Distance from foundation--------------------Distance to nearest lot line.................. Number of:lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- 'r-1► Type of filter material-___ Depth of filter material___--_____-_-______-_Total length_______ _________ _-__ See a Pit: Distance to p g nearest well_��Z „l__. istance�f'om u dation---��Q-- ------.Distance to nearest lot(m9 Number of pits-----/---------- ---Lining rnaterial__!%dl�ize: Diameter-2-k-11. .___.Depth.:---A ............... r s Cesspool: Distance from nearest well-----------------Distance from foundation _.-----------------Lining material------------------------------- 171 ________________•___-_,___ ❑ Size: Diameter .--- #Depth t--------------- -----------------Liquid Capacity-----------------..........gals. Privy: Distance from nearest well ___z--------------------._._.,:___Distance from nearest building___-•_ _______________________________ ❑ Distance to nearest lot life---------------- -------------------------------------------------------- ................--• -•-------- Remodeling and/or repairing (describe):__,. ` _ ._ __ ___ _____ �j/ ----------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------•--•-•------•-•-•-•----- -••---------------------••-------------•--------.---•------------------•------------------•--------••----------------------------•--------------------------------•-•--------•-------.._ -- --- ------ --------------------------------- ------•-••-----•----••---•-------------• -•-•--• --•••---••••------. -----------••------•-••--•--------------------------------- I --------------- ---------------I hereby certify that I have prepared this ap�piication and that the work will I be done in accordance with San Joaquin County ordinances, Sta a laws, and-rules and regulations of'the San Joaquin Local ealfh District. (Signed)---------- ---•--•-. ;---��--------- .'-. • • - ( er and/or Contractor) BY� -------------------------------- - (Title) •��'a�-r 'fir (Plot plan, showing size of lot, locafiion of s fiem in re anon to wells buildhtl , etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ,,ej ... ., DATE_ ------ REVIEWED BY------------------------- ---- `--`--------- ------------------------------------------ DATE . ..._,� . BUILDING PERMIT ISSUED................... ---1-------------=---_'` ------ 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-9-21v! Revised W-2100