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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in in Duplicate) Date Issued _. ---T:-• � 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,wit Count Ordinance No. 549. JOB ADDRESS AND LOCATION....----- r___ '± T�-_..------Z[/�c�J� 4_� -c-v �'- -, -_•__.. 7-� d-c`i ./�i -- -------------------- Owner's Name_--X2"j.______ -C!-----__- -•-------------------------------------- - - --------------- ------------ --------- Phone------------------------------------ Address----•-- -y-urv-1-t {{� �V Contractor's Name-------` - s= ----- •-•------------------ ---- Phone-- --••- ---- -- --- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms --I-_ Number of baths _',__-- Lot size -------------------------------------------- Wafer _____________ _____________________________Water Supply: Public system ommunity system E] Private E'] Depth to Water Table--------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 011"'Clay ❑ Adobe❑ Hardpan ❑ l 6 � {- Previous Application' Made: Yes No { pp ❑ � New Construction; Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted-if public sewer,is available within 200 feet.) Septic Tank: Distance from nearest well___Mance from foundation__:3C7________.Mafe iai____S h2Cit e Jr[C c y Q No. of compartments uid de th--------- ----------- Capacity- ® "�" 7 p ---------�------��Size-- - �'�'��-'{"L� ' p - ---- f�---- -------- � Disposal Field: Distance from nearest well-.Til'_____. lance from foundation---/�S-_•_______.Distance to nearest lot line/4_-c_____ Er" Number of lines___________ __________________Length of each line_________ _ __,4__--Width of french---21/----____..-------------- Type of filter material-_'/�_Qr.<--------_Depth of filter material-___l, --------------Total length------IX-0---�?v I{ Seepage Pit: Distance to nearest well______ ________Distance from foundation---.---------:__._..Distance to nearest lot line________________ ❑ Number of pits'----- --------------Lining material-----------------------Size: Diamete'r----•------------------Depth--------------------------------- j Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 4` ❑ Size: Diameter------------- --+--------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------°___-.----------------------------------___Distance from nearest building____-------___--------------------------, ❑ Distance to nearest,lot line--------- -------------------------------------- ----------------------- Remodeling •----------------•---Remodeling and/or repairing (describe)--------------------------------------------------------------•-------------•---•------•---------------•---------- Z ---------•----------------•---- -------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------ •------------------------ -•-'------..-_.-------------------------------•-----------------------------•---------•-•---------------------------•---•----•---•-------------------. ---------•--•------------------------- ----------------------------------------------------•---------------•--------------•----------------------------------------------•---------------------------------------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. {signed] � ! ---------• -----------------------------------• {Owner and/or Contractor) ------ --------------I----------(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 APPLICATION ACCEPTED BY.,,,-04—__ ._ DATE-•S' ------------------------------------------ REVIEWED �b --- -------------•----•----------------- REVIEWEDBY--------------------------------- ----------------------------------------- •------------- DATE-------- BUILDING PERMIT ISSUED-------- --------------------------------------------_---------------------------------------------- DATE - Alterations and/or recommendations-------- ---------------------- ---------------------•----------------------- -----•=------------------••------•---------------- ----••----------------•------------- --- ------------------------------------------------------------••-------------•-----------•---•------••-•----------•----•---•---. ---------------------------------------------------•----------------- -----i---------------------- --------------------•-------------------•----------------------------------••-----------•------------ •---------'---- ---------------------------------------------------------------------•---- --------------------___-- -•---------•------------------••---------- •-------•--------------------•-------------- ---------------- ---------------- --- --------------------------------------------- --------------------------•-•------- FINAL INSPECTION BY --- -- -------------- Date --------------------------------------------- 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 i ES-9-2M Revised W-2140