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1 � APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) uy Date Issued Applica}ion is hereby made to the San Joaquin Local Health District for a per it to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN C 10 --- ---- �----- .------- - -------- Owner's Name______ _ __- r -1' ' - ----- --------------------------------- Phan- d_ .... Address---------------- -- - Contractor's Name--------------------- ------------------- --------- -------• - -•------------------------•------------•----- Phone---------17 lold Installation will serve. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/1___ Number of bedrooms a .• Number of baths --/--- Lot size . __ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe* Hardpan ❑ Previous Application Made: Yes ❑ No.4 X New Construction: YeA No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well_________________Distance from foundation--------------------Material_______.___-.______________________------------. " No. of compartments--------------------------Size------------------------•-----..Liquid depth--------------------------Capacity----------------------- isposa ield: 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------------------- Depth er ma ial_____________.________Total length-------___-._----------------------------- Seepage 'pit: Distance to nearest well_,�r'4 '�_____ ante fr m fpu at on---� .______.Distapce to nearest lot line__.____ Number of pits------/-____.._.____Lining aterial_ ... . ze: Diameter.--.___....____.__Depth_______ ± t. 1 Cesspool: Distance from nearest well----------------- om ndation--------------------Lining material _.________-____---__-_----._________ .r ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. LF! Privy: Distance from nearest Well ____--------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line---- -------- --- -------------- ----------------------------------- Remodel nd/or repairin scribe}: �` 'ec o-- -- --� --- ---------- ------------------- ------- ° -----------------•---------------------------- --------------------------- ______"___ - A -c� - - ------------------• -- -- ----------- ------------------ --------------------------------------------------------------------------•--.--.----••-------------------------------------------------------------------------- I hereby certi W fhat I hay prepared this application and that the work will be done in accordance with San Joaquin County �;-0, ordinances, State laws, and r nd regulations of the San Joaquin Local Health District. Q (Signed)------------- �----------------------------------------------- ------------------------------------------------------------ weer and/or Contractor) BY� 9of - ---------------------------------------------------------------------------------------------(Title)-------- /everse '-------••-------------------------- (Plot plan, showing sizt, location of system in relation to wells, buildings, etc., can be pla ed o side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - � DAT — REVIEWEDBY--------------------- ---- - ----------------------------------------------------------------------------- --- DATE--- -----•------------••-•------------..._... BUILDING PERMIT ISSUED-----------------------------------------------------------------------------------------...-------•-- DATE—_ Alterations and/or recommendations:----------------------------- ---------------------------------._..._......----------------_---- �'\-----------•-------•---------------•----------- - ----- t---- ----------------------------- -- ---- -------------------------- ---------------------------------------------------------------------- `�`"_' S ------------ Date---- 1 S�5 FINAL INSPECTION BY-----------------------------• •--------------------- --------------------------------- -------------------------- SAN -- ----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 ; LRevised W-2100