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1P APPLICATION FOR SANITATION PERMIT Permit o. __7 CliDuplicate) (Complete n upcate) 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. I JOB ADDRESS AND LO ATION_.__-_-----�-- ---�- - � Owner's Name------------------ ------ -- -- --- -- - -- -- --------.. --------- ---- ---- Phone--------------------- f ------------- Wk },� p -Address--------------------------------- --- ---- -- ---- --- ---------- •--- Phone-- �6 ---------- Contractor's Name------•W-1-4Q - ��---"` ----- - - l--- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ 'Trailer Court ❑ Motel ❑ Other ❑. Number of living units: Number of bedrooms�G____ Numb�ofe'PDthe _ ___ Lot size _____ _. __�-- -----f_ ------------Water Su ! Publics stem Communit s stem Privateh to Water Tabled-_ ft. PP Y= Y ❑ Y Y ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe eHardpan ❑� Previous Application Made: Yes ❑ No �ew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -------- --- �� f�--____--.Material-- _��__�-- -- -- ------------------ Septic T k: Distance from nearest well________________Distance from foundation__ _- of compa4ments_- -___. Size--- -,�'1 ��!Liquid de th__�- _ Ca Capacity N--- No. --_--- p P Y Disposal Fi !d: Distance from nearest ell- t1Q------Distance from foundation_,`_-_____---Distance to nearest Number of lines_____ _________ Length of each line _d_' _d _.Width of trench___---C---- r Type of filter ma rial _ _��__Depth of filter material__/_ ---- ------Total length___,l ---__�/- -------------------- Seepage Pit: Distance to nearest well_---------------------Distance from foundation------------.-------Distance to nearest lot line_-_______________ ❑ Number of pits----------------------Lining -----------------------Size; Diameter-----------------------Depth_... _------------------------- Cesspool: Distance from nearest well_________________Distance from founclation___-------_______.Lining material_____-___-_____________________--_ ❑ Size: Diameter -------------------------------------Depth-------------------------------- Liquid Capacity gals. w., .� - . " Distance•froni near4st weH___-_. _---- -- -- ------ - --Dis' tan'xe�e'Trorn n"" est building______-_ ❑ Distance to nearest lot iine------------------------------------------------ --- ---- -------------------------------------------------------- Remodeling and/or repairing (describe):----------------- ----------- ------------ --------------------------- -------------------------------------1-1----------•---- --------- ------------------------------------------------------------=-------------------------------------------------------------- ------------------------------------•-------------------•----------------------------------------------------------------------------------------- -------- ----------------------------------------------------- --------------- -------------------------------------------------•-------------------------------- ---------------------------------------------- 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 Loca Health District. - [Owne nd/or an+rac#or) (Signed) ,. (Tit ------------ By:..... - 1 / r ------�----------- ---- le) [Plot plan, showing size of lot, Loca+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r I APPLICATION ACCEPTED BY------------- ---------- ---- ----------- ----------------- DATE- ------- ----- -- DATE_ --------- ------------------------------------------- BUILDING ------ - - - REVIEWEDBY---------------- ------------------ - -------------- -- ---------------------------------------------------------------- - -------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------------- -----------------------------------and/or recommendations:------------- ------------------------------------------------------------ = ------ ------------------------------------------------------------------- ------------------------•-----------•------------------------------------ - ----------------------------------------------------------------------------------------------------------.---------- ------------------------------------------------------------------------1_____Z------------- ------------------'---------------------------------------------------- -------=------------------------------------------------i------------------------------------------------------ -------------------------------------------------------------------- FINAL INSPECTION BY------------------ `! ' C Date---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American .S+reef 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