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.MIo APPLICATION FOR. SANITATION PERMIT Permit No. 01.7...... (Complete in Duplicate) 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. s � --------------------------••-- f JOB ADDRESS AND C TLO ---------"-iJ> � - '�' ' � ----- Phone__ ._ ------- T_ -._. _'_- � Owners Nam - •---- •-�`/_-- - -�-�`-�-------- --- •-�'�—�f----- -------- ------------------------------------------------ . Address. ------ --- --------- ---- - --------------------------------------------------- ---------------- ----------------- Contractor's Name_----- -- --• ...... rte j--- ------ _•------------------------------------ ------- Phone - _ _ Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer,Court ❑ Motel Other ❑ ; Number of living units: _/--- Number of bedrooms Number of baths _/__ tot size -- - ----------- Water Supply: Public,systemCommunity system ElPrivate L] Depth to Water Tab[e, — Character of soil to�a depth of 3 feet: - Sand F] Gravel E] Sandy Loam [I Clay'Loam ElClay ❑ Adob� Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ' No ❑ E �I TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) j Septic Tan Distance from nearest we!!________________Distance from foundation____________________Material----------------------------------------_______-. No. of compartments-------------------------Size------- -------------------,_°.Liquid depth-------------- ---------Capacity----------------------- Disposal .iel Distance from nearest well---___.________Distance from foundation_______-____._.----Distance to nearest lot line_________________ Number of lines-----------------------------------Length of each line-------------------------------Width of french-------------.----------------------- Type .______--___--------- V� Type of filter material-_____________________Depth of filter material----------------------- length---------------------------------- Seep ________-_-________--- __________ : 5eepa e Pit' Distance to nearest well --_Distance m fo dation_' -,_____.Distance to nearest lot li T__a�___.. Number of pits------�------------Lining material-----ll----Size: Diameter_- .r______------Depth-------. --------------- . , Cesspoal; 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:---- -------- ------- ----=----------•- ------ -------------------------------- �11�_? A <� :r ---- •-----—--' ------------------ Remodeling and/orirepairing [describe}:_...� _ _____ _.y� - -)------ --- �-----------, ----- ----------------- - •fes__... _ /aree4 ------•------------------------------------- ----•---------------------------------------••----------•--------I hereby certify that l have prehis application and that the work will be done in accordance with San�Joaquin County ordinances, State-laws, and ules and regulatio of the San Joaquin,Local Health District. /,/5 _ __-___n_------Owner and/or Contractor ( itle l i By:..................••'-=- ...--- �--- -------------------------------------------------- T = (Plot plan, showing size o�-lot, location o system in relation to wells, buildings, etc., can be pla don reverse skde}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �1Zh I- - ------------------------ DATE-------�J �' S --------------------------- REVIEWEDBY----------•------------------ ------------------------------------ --- DATE = = BUILDINGPERMIT ISSUED----------------------- -- ------------- --•--- DATE--------------------------------------• -------•----------- Alterations and/or recommendations----------------------------- ------------------- --------------------: -------------------------------------------- x .. --------------- -------•------------------•-------------------------------•-------- ------------ -----=----- # FINAL INSPECTION BY:----------- = � ------ Date--------- - 'Z - - ------------------------------------------------ SAN 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