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APPLICATION FOR SANITATION PERMIT Permit No. 16._4R_=-:F (Complete in Duplicate) 6 ,! �� __.� .. . ..�.. Date Issued e Applica+ion is hereby made to the San Joaquin Local Health District for a permit to constr, t stall the work herein described. This application is made in compliance with County Ordinance N 49. _ __ , JOB ADDRESS AND��LOCATION -- ---- -------- -------- - -- --------- -------------- Owner's ---------- " Owner's Name_-.---.�d___r ! --------------— - --------- ------ -- Phone----•--------- w r Address. T = = --------- Contractor's Name-----..... 5 ) I --------------------------------------------------------- Phone Phone -----------f 4 Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of livin' units: _ ._-_- Number of bedrooms __Number of baths Lot size _ _ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ T- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Xe Hardpan ❑ 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-----------------Distance from foundation----------------.__.Materia(_________________________._-N._________________' ❑JAUS111{4;' Noof compartments- ------------------------Size--------------------------------Liquid depth------------------------- Capacity Disposal Field: Distance from nearest well------------------Distance from foundation--------------_____.Distance to nearest lot line-------- S-ri/S va Number of lines--------------------------------- Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material------------------------Total length--_--------------------------------------- Seepage ------------- = p g �Am_Distance rom f ndation_. /� See e Pit: Distance to nearest well__ __ . - a��_______.D's ta��ce to nearest lot line____(/__.____ Jr Number of pits---(�71.�r.: Lining material__�;�--Size: Diamefer__ -_ _.___._De fh_-. ` W p �------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------______.___. ❑ Size. Diameter--------------------------------------Depth---------------------------------------=------------Liquid Capacity---------- -----------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-------------__-_______--___-------__---. Q ❑ Distance"to nearest lot line---------------------------------------------------------------------------------- Remodeling and/or repairing (describe:_______ -----------------__ ____-.. __ Q ------ 9- ---------------------- ----------- -------------- - --- ---------— -----------------_------------------------------------------------------- --------------•---------- , ---------------------------------------------- ------------:- -----------------•---------------•----------------------------------------------------..._-- I hereby certify that I have prepared his-application and that the work will be done in accordance with San Joaquin County ordinances, State laws,and and regulations of the San Joaquin Local Health District. (Signed(----------------------------- - _ `"' -------- =----------------------------------------------(Owner and/or Contractor) By------------------------- �" (Title} f1 (Piot plan, showing size of lot, location of system in relati n to wells, buildings, etc., can be placfn reverse side). FOR DEPARTMENT USE ONLY - x APPLICATION ACCEPTED BY - -------------- ------------- DATE--------- ---- !`'= 4� REVIEWEDBY--------------------------- -------------------- --------------------------------- --------------.------------------------------- DATE-.----------------- -- •--.----------- BUILDING PERMIT ISSt.IED----------------------------------:------------------------------------------------------------------- DATE-------------------- ------------- Alterations and/or recommendations:--=-•-------•------------------------------- --.-------------------------------------------••---•-----...----•----------------•-•---------- -------------------- --------------------•----------------------•--------- ------------------------------..----•--------------••---•--------_------.....---------------------------------------- ---- --- -----•-•------------------•--------------------------------------------------------------------•--------------------- FINAL INSPECTION-BY:_--`. . . ------ '_ .. .------- Date------fes - 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 f