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APPLICATION FOR SANITATION PERMIT Permit No.,�?.Y --- (Complete in Duplicate) &I , - � J Date Issued Applica¢ion is hereby made to the San'Joaquin Local Health District for permit to construct and install the work herein described. I This application.is made in compliance with--County Ordinance No. 549. r ( r J08 ADDRESS AND LOCATION_. p--�'- -�_-.-- ----- -_ Owner's Name----------- - Q ' - A - - � -��-- -� - ---------------�- ----------- -- hone_ O 3 . .�•— Address---•-------------- _ r - Contractor's Name--------- - =``c- r Phone Installation will serve: 'Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number-of living units: .____ Number of bed'room's ____9!Number of baths _____� Lot size ------ —2 S_"-___ ------------- Water Supply-: 'Publics stem I y (X�.YCommunity sysfem ❑ Private ❑ Depth to Water Table !, pft. Character of soil to a depth of,3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Ad obejg—Hardpan ❑ Previous Application Made: Yes ❑ No s6?_ New Construction: Yes ❑ No ❑ `y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Tan ;, Distance from nearest well_________________Distance from foundation________.__:___. -.Material______.__.-------- ----------- No.,of compartments----- -------------- ---Size---•-----------------=------,...Liquid dep'th-------------- ----------:Capacity---------=--- ----- vsal e�dr- •Distance um nce from lines earest well--"-"------------ _._ - is aof.each line foundation------------=-s__-_-Distance to nearest lot line...... ____--___ �� 'Length ------------Wrdth of trench---------- ----------=-=----- Type of filter material-----------------------,_Depth of filter material--------•--------------Total length---.__------------------------- Seepage Pit: Distance to nearest well_. -4 _Distance fro foundation___��/__.Distance to nearest lot line__�d___ XNumber of pits__:_ ______________Lining material__ -Size:.Diameter_. r -�- --- ------ �-� r-----------Depth--------'�-- --�-------------- . Cesspool: Distance from nearest well------------------Distance from foundation___._.__--.___'_____Lining material..___.._k______ ❑ Size: Diameter------ -------------------- . ------Depth-------------------------- - Liquid Capacity gals. Privy: Distance from nearest well____ ---------------------------------------_._Distance from nearest buildin } 9 ------------------------------------ ❑ "' "--Distance to nearest lot line-------._.-----:w-_ •».---------------------- - ---------- Remodeling and/or repairing (describe):------------------------------------------------- `-------------- ------- -------------------------- ----- # _= ----••--------------•---------•--•------•-------•------------------------ ------------------------------------------•-----=------ ------------•---- ---------------------- ---------------- -------------------------------•- --•-------------------------------•------------------------------------•---------------------------------------------------•------------ ----- ),hereby ertif that I have prepare this application and +hat the work will be done in accordance with San Joaquin County ordinances, S to s, andnd raga ations of the San Joaquin Local Health District. (Signed)---------- - --------- - ---------�------------------- -- ----- -- --------- ---- --•- -- ------------ Z Contractor) . i - wnBy----------- -------------•-----=--------------=------ --- _ br-- ---- (Plot plan, showing size of lot; location of system in relati n o wells, buildings, et ., can erse side). T FOR DEPARTMENT USE ONLY I APPLICATION,ACCEPTED BY------------ ' ;5 DATE__. 3 REVIEWEDBY ='r- -----.---------------`---------------------------------------------------------------------- DATE - BUILDING PERMIT ISSUED ----------------------- ---------------- --•---------�----------•------•---- DATE-------------------- Alterations and/or recommendations--------------------------- =:-.- --- ---------- i ------- ----- ------•----------------- ------ ----- -----`--------------•--- -------------•-------------••------------.....----------• ------------•-- f ---------•-------------------------------------------------------------- ---....---------------------------- --------------------= --- -• --•---•-------=-----------------------------------•----- , -------------------•-------------------- - -------------------------------------- ---------------------------------------------- FINAL INSPECTION BY-_..:_-:-._.r. ---�----:- ."c" .. - 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 Revised W-2)00