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n . APPLICATION FOR SANITATION PERMIT Permit No. li D i C ( omplete n Duplicate) ,y� ,J �► Date Issued ..1__? /- 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 compliant with CountyOrdinanceNo. 549. --------------------- JOB ADDRESS A ------ V , Owner's Nam ------ Phone----- /� ---------- -------- --------- ------------------- ------ - Address !1 ----- •.... ` ---- ----------------------P ------------------------------------------------------------------------------. k � _ ., Contractor's Name---v�......" --------------------------------------------------------------------------------- -- ------ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Traileroi curt ❑ Motel C] Other ❑ Number of living units��Number of bedrooms ---Z_. Number o baths Vat size -C V11-9-_xZ.Q_-Q.- ------ Water Supply: Public system El Community system E] Private Depth t Water Table ------:_ ft. Character of soil to a depth of 3 feet: Sand F] Gravel ❑ Sandy Loam Clay Loam [:] Clay❑ Adobe❑ Hardpan ❑ Previous Appliqation Made: Yes ❑ No [!( New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu li #ewer is available within 200 feet. I �v � ------._.Mate ill-- ----------._ Septi ank: Distance from nearest well__^?�-__C� ___Dsta�nf�e from foun tion_....__ � -- No. of compartments-----.-----hl--- /-._Size_T-..[_�_l__!L4_!`i ___Liquid dept h.-------�------------Capacity-----_______-__.�_---- Dispo Field: Distance from nearest w II _Distance from foundation.. _ ..�ij._.._.Distance to nearest lot line_ .r ._.... ( Number of lines___ ___ _________ ______ Length of each line_._____._ Width of trench___________' Type of filter materi QQ�� / pth of filter material Total length----- ..., " ... Seeps Pit: Distance to nearest well-___-- _�._-----Distanc , from do to c o nearest lot sine----�.---. 77 Number of pits._.___1_____________l-ining material._ __ _.. ize: Diameter___._..�!-�___Dept h_.__�.�_,_------------------- -fro ..__________________.__ Cesspool: Distance from nearest well_________________Di*ance from foundation-____.--__--_--___.Lining material_____._._._.__.________.___________:: ❑ Size: Diameter-------------------------------------Depth------------------------------------------ -•----Liquid Capacity-------_------------------- Privy: Distance from nearest well -_______.-___---------------------------------Distance from nearest building--------------------___--____._-.-___-.. ❑ 1 11Distance to-nearest` let line-`--------- - ---•--------------•-----------------------------------•-------- Remodelingand/or repairing (describe):----------------------------------------------------•---•------------------••---------------------------------------------------•------------------------ -------------------------------------------------------------------------------------------------------------------------------------------•------------ - - -------------------------------------------------------------------------------------------------------------------------------•------------------------- 1 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 regulations of the San Joaquin Local Health District. ----------------------------------------------------------------------------------(Owner and/or Contractor) (Signed) --------- ----------------------------------------------------------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------------------------------- ---- -- --------I— ---------------. DATE--- -- ----------------------------------•------------ ----------------------------------------------- BUILDING PERMIT ISSUED-----_-_--------------------------------------------------_-------------------------------------- DATE----... Alterationsand/or recommendations--------------------------------•---------------------------------------------------------------------•-----------------------•-------------------------------- -•--•--•---•---•-•-----=---•---------------------•--------------•-------------------------------- -------------..................................................------•-------- -------•••--------•----------• --•--•--•----•-------••---•••-------...... - ••---•--•-•-••-••---••------•------- ------------------------------------------------------------------------------------------------------ ---------- --------------------------- -------- --------------------- FINAL INSPECTION BY--------------------------------------------------- Date...-------- ./___Z 1 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