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1 APPLICATION FOR SANITATION PERMIT Permit No..�—(Complete in Duplicate) Date Issue �rO ..;'f_._... Applica4-ion 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 Ordi nce No. 549 JOB ADDRESS AND LOCATI N____-- _7c - __-- _-- -- - - ---- - -------------------- --- ----------=---------------------- - - - ---------- --- Owner's Name -' --•-- ------------ -- I?hon 7- Address----------------••-- . -• ------- ------------------- ------- -----..._.... ---- ------ Contractor's Name____________ -- -_Q -�.�a ------- ------------------------•------------------------•--- Phone.GSF�/ 6_-9Q� --7-- Installation will serve: Residence 2,-�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r /� ► Number of living units: ___r___ Number of bedrooms .-ca- Number of baths __.j___ Lot size ---(R-�____�_/ � ----------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _XQ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe D-'Hardpan ❑ Previous Application Made: Yes ❑ No � 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-----------------Distance from foundation________.._-__.__.Material______________._________--___________--_______-- ❑ No. of compartments--------------------------Size--------•-----------------------Liquid depth------------------------- Capacity-----------•---- ------ W Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_______...__..._... ❑ Number of lines-----------------------------------Length-of-each line------------------------------.Width of french----------------------------------- a Type or filter material-------------------------Depth of filter material-----------------------Total length-----------------------------.------------ Jr h Seepage.Pit: Distance to nearest welL.____�---------Distance fro fouy�dation__--_ -- is ante to nearest lot line� �_�____ Number of pits-------,------------Lining material-a- -Size: Diamete r__ _____--------Depth____4�------------------ 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-------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------- Q -------------------------------------------------------------------------------------------------------------- =` ------------------------------------------•-------------------------------- •---------------------------------------••-----------------•--------------------•----_---------------------------------------------------------•--......_:---------------------------•--------------------------•------------ i ---------------------------•--------------------•--------------------------------•----------------------------•----•-------•-----••-----••---------------------•-------------------------•--------------------------- ------ 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 rules and regulations of the San Joaquin Local Health District. . I is ------------------------------- --------------- -- - - - Sxer and or Contractor (Signed)---------------- _ , - ) 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 APPLICATION ACCEPTED BY---------------------- -- - -- -- ----- - -- ---------------------------------------_ DATE----- -� - - - REVIEWED BY '!__ -- ----- ------ -- --- ----------------- DATE---------G -�-. --------- -- - - -- -------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- Alterations and/or recommendations------- ---------- -------- ------------------ ------------------------------------------------------------------------------.._.-._....-------- -----------------------------------•------------------------------------------------------------------------------------------------------------------------------•-----------------------• ---------------------------•----- -----•----•----------------------•-•----------•-------------..------•-------------------------------------- -------------------------------------------------------------- ------------•------------------------------.._..__. - --------------------------------- --------------------- --------------------------- ----------- ----------._.-.-------I--------------•-------•-------------------------------•-•--------- ----------------------- J GFINAL INSPECTION BY:--------V It"n------------ ------------- Date- ----- -- G -------- - --------- --- 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-4-2M ; Revised W-2100