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U APPLICATION FOR SANITATION PERMIT Permit No. e ca up n p (Comlete iDuplicate) _ Date Issued Application 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. JOB ADDRESS AND LOCAT ON__-..---_-_- r3G___.___;5-7 - _ ----- 4- V------------------------------------------------------------------------ Owner's Name----------------- - -- ---- -- --------------------------------------------- Phone---------- ------------------- �. Address-------------------------- ------- Contractor's Name----------------- - ----------------------------------------------------------------------------•------------------ Phone------------------ ................ Installation will serve: Residence partment House ❑ Commercial E] Trailer Court ❑ Motel 11Other ElNumber of living units: /_--- Number of bedrooms --/-- Number of baths V-_-- Lot size ---------- -----. -- Cf -------------- -- Water Supply: Public system ❑ 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 [ !o New Construction: Yes 0 No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septit Tank: Distance from nearest well--AcAc P C-Distap9e,�fro fpu&- on__/-,0- _--- -'1l--------------- i No. of compartments-------�---- ____-Sy3 j(- R.-KLi uid de depth �---1 ---- C. a acity--- Di osal field: Distance from nearest*cell--1/ZX tDistance from foundatign-- --Q-- --_ Distance to nearest lot line_-- ------- -Length of each line -�:`-__ Number of lines------------ --'- _-- � �'� ------ Width of french------__7"� Type of filter material----L- - _- -- epth of filter material---�_ - Total length_----/ .-- ___ -------- Type -;---- Seepage -Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest Iot.line----------------- - 1] "' Number of pits----------------------Lining material-----------------------Size: Diameter--------,---------------Depth--__----_-_-------____-_--------- 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._---.------____-__--_--___-_-_---._ Distance,to nearest lot line------------------------ -------------- I Remodeling and/or repairing (describe):------ --- -------------------`--------------••- w - --- ------------------------------ -- -----•-------- -------- -----------•------------•---------- -------- •-- - - ---------------------------------- -------------------------------------------------------------------------•--------------------------------•-------------------------•----------------•----------------------- 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 ru s and regulations of the San Joaquin Local Health District. (Signed)-- 'LI , -----------------------------------------------------------------------------------------(Owner and/or Contractor) BY� -----------------------------------------------`--------------------------------------------------------(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 �I APPLICATION ACCEPTED BY---------------- -r---------------------------------- ----------- ------------ DATE------- REVIEWEDBY--------------------------------------------- ------------------------------------ ------------------------------------------ DATE----------- BUILDING PERMIT ISSUED----------------------- -- ----- -- '- `= DATE _ ------------------ ------------ - � -- Alterations and/or recommendations: - ---- --------------------- ----- -- --------- ------ 1` ------------------------------------------------------------------ T - -------- -- -- --------�-- - --- -------- - --------0- --------------- --------------- FINAL INSPECTION BY:-------------�f%�.✓L� -------------------------------- 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 8-5I Revised W-2100