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� QA LIGATION FOR SANITATION PERMIT Permit No. q----- � (Complete in Duplicate) d ( 7 �1 ` Date Issued Application Is hereby made to the San Joa u Local Health District for a permit to construct and install the work herein described. This application is made in compliance with unty Ordinance No. 549. JOB ADDRESS AND LOCAFaON•.--- - --—--------- --/'�----- - - -----7---------------------------------------------------------------------------------------- Owner's Name--- ----- ------- --- ----- ---t - r " _ `""' ------ Phone.__`_ `J"/�r_ , Com. -.....a.. Address_.__ ------- - --------------------- ----------------------------------------------------------------------------------------••--------- ----•-•------- Contractor's Name -------- Phone--------- -3- Installation will serve: Residence' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms2-___ Number of baths I___ Lot size ----' r� X 0._4�.__.--____ Water Supply: Public system Community system ❑ Private Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam ❑ Clay ❑ AdkHardpan ❑ Previous Application Made: Yes No ❑� New Construction: Yes [:] No� TYPE OF INSTALLATIOAND IFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_.____._-_-__._.___-____..______.___..__________- j/)/ o. of compartments-------------- -----------Size--------------------------------Liquid depth--------------------- --.Capacity----------------------- Disposal Field- Distance from nearest well --- -------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-----------------------------------� Type of filter material----------------------- of filter material ___________-___-/---Total length________________________________________- Seepage Pit: Distance to nearest ells- . -- ----Distance fr m fou ation_._ ------.Distance to nearest lot iine__�______ Number of pits._.___-----------Lining material__ ___ ______ ___Size: Diameter--- .. -----------Depth...... ----____.______ Cesspool: Distance from nearest weiL________________Distance from foundation__------------------Lining material______-____.__..________._..___-_____ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__._________._________________._._. O ❑ Distance to nearest lot line-------- --------------------------------------------------------------------------------------------------------------------; --------------- Remodeling and/or repairing (describe):---------- -- - -- --------------- ="--------------•------------------ ----------------------------r-------------------------- -----------------------------------------------•----------•--------•-•---.--------------------------------------------------------------------------------------------- ---------------------------------------------------- --------------------------------------------------------------------------•------------------------------------ ------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County v ordinances, $tate ws, �nres and r tions of the San Joaquin Local Health District. Si ned ---��-'---------------------------------------- ------------------ --- --- -------- --- Owner and or Contractor{ 9 )•.--------- - -- / ) B •._...- -�- '-------------------------------------------------------------------------------------------(Title)- de).,- y { ) ;�=----------- - - (Plot plan, showing Ize of lot, location of system in relation to wells, buildings, etc., can be plaid on revers�ide)r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ----------------------------------------------------------------------------------------- DATE-�-------------------------------- ----------------------- REVIEWED ------------- ------- REVIEWEDBY------------------------------- - ------ - ------------------------------------------------------------------------ DATE------1�--------------------------------------------------- BUILDING PERMIT ISSUED---------------- ---- -- DATE------- G� Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------- ----------------------------------- --•--•-----------•-------------------------------------------------------------------------------------- •------------•--------------------------------------------------------------------------------------- ..---------------------------------------------------------..---------------------------------------------------------•-------------------------------------------------------------------------------------•-------------- ----------------------------------------------------------- --------------------------------------------------- -------------------------------------• -------------------------- ----------------------------------------- FINAL INSPECTION BY:............. ---------------------•---------__-._-- Date......-------x/- -. • i�ll 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 10-52 Revised W-2100