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APPLICATION FOR SANITATION PERMIT Permit No. __ �� (Complete in Duplicate) ) (� S • Date Issued -----j-j---j---3 Application is hereby made to the n Joaquin Local Health District for a permit to construct and instLall the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION______________ _ _ °2� 3 -------------------------------- Name---------------------F-f---•----..F.I ? 4. `{` -------------------------- ----------------------------- Phone------------------------- Address-------------------------------------•------------------------------------------ Contractor's Name----------------------•-- ----------------- --------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence CK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ,, Number of living units: -------- Number of bedrooms _ ___ Number of baths ._-t__- Lot size -----------_ _Q____k---24P___________________ Water Supply: Public system 4 Community system -[] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay -Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ NoA— New Construction: YeSA 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_-__- P__.-_.___.Material_______-t -Ot' <' - `�-0_---------- _______ No. of compartments--_-______D.._-----------Size-____-_-S"�t_ X_, -----Liquid depth---_-___-42,...........Capacity------ i Disposal Field: Distance from nearest well-------h*_-___Distance from foundation_______N.1------Distance to nearest lot line____________ Number of linen______________ ---�-----Length of each line-----.---TS- - ---____---Width of trench----- -a_ r�________________ t Type of filter material________________________Depth of filter material-----------------------Total length____---_---_____--_______________________ F Seepage 'st: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line________________. Number of pits______________________Lining material-----------------------Size: Diameter____ 1 p f 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------------------------------------------ ElDistance to nearest lot Iine------------------------------------------------ ------------------------------ ----------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------- ---------.._.....------- ----------------------------------------------------------------------------------- rt'- " -----------------------------------------•--------------------------------------------------- ----------------------------------------------------------------------------------------------•------------•--•--------------------------------------------------------------------------------------------------------------- --•------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I 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. ---- ------------------------------ By: ---------------------- - (Owner and/or Contractor) (Signed) -------------- -�" By:---------------------------•--------••---------------------------------------------------------------------------------------------(Title)--------------------------------------------------------------- (Piot 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 6Y-------------------------------- ...... DATE ---/- 00/ ----- -- REVIEWED BY--------------------------- �-------------- --------------- -------------------------� -- ----- -- - -------- DATE -------------------------------- - ---------------- BUILDING PERMIT ISSUED--------------------- --------------------- .---------------- DATE Alterations and/or recnmrnendations:---; _^a`EJ_ oS .a a�.��iu.�a� amt }_ --------------------------------- ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________..______________-_..-_________.-_-_______________-_______---_.__----_____._________________.____________________---_---.-.-__._--------__---..-------------___.--_______-_- ___---______________---_-__---_ 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 8-51 Revised W-2100