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f• APPLICATION FOR SANITATION PERMIT Permit No.rdecribed. mplete in Duplicate)(Co Date IssuedApplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he This application is made in compliance with County Ordinance No. 549. ` II ��.)-----------Sar f----------------------------- JOB:AQQRESS AND LOCATION------------------- - f n - -��--- - --------------------------------------------------------- •---- Owner's Name----------------------- I�---•----&-&,4c 1----:-------1 Phone fi t / Address.................................. !I� -------•----------- ....... ---------------------------------------------------------------------•--•- Contractor's Name. .... Sf3�'h.� ----------------------------------------------------- Phone Installation will serve: Residence jX Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:l___.____ Number of bedrooms 3.- Number of baths ---1_Y,-Lot size ----------t7l_--______________ _ -------- Wafer Supply: Public system'[X Community system ❑ Private ❑ Depth to Water Table -------- ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: YNo E] 11 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) NO -- p r � -1 Septic Tank: Distance 4om nearest well___J.y_�____Distance from foundation_____tV_r_-___.Material________--_,Re�r�d __________________ No, of col partments--------------�--------Size____ -/ -- _-•_Liquid depth-----------Y-Y........Capacity_..-.'�d fr-/ Disposal Field: Distance from nearest well--------ft....Distance from foundation------- 1_.�..Distance to nearest lot line-----,- ❑ Number of lines-------------------- -----------N Length of-each line----------.C�Cf_'`......Width of french__________--7-A/__'l_____________ - Type of filter matercal------- --t,- ! ---Depth of filter material---------117--" length-----.•----,f --------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____-______-,--. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------.--_______--------- Cesspool: Distance from nearest well-----------------Distance from foundation----------.---------Lining material-----------------------------.------- Size: Diarrieter--------------------------------------De th------------------- --------------------------------Li Liquid Capacity-. ❑ p q --------------------------ga 1t. Privy: Distance from nearest well____________________________________---_---.----Distance from nearest building________._.______._______.______..._. ❑ Distance to nearest lotline---------_------------------------- --- --. i Remodeling and/or repairing (describe):-----------= - _` ----------•---•---------------------------------•----------------•----•-•---•----------------------------------------------------------------------------•------------------------ ------------------------------------ --------------------------•------------------------•-•-•----•----—------------------------------------•--------•------------------------------------ -----------------------•------•----------------------------------------•-------------------•-•-----------------------------• -------------------------------- I hereby certify that 1 hive prepared this-application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and regulations of the San Joaquin Local Health District, a (Signed)-_• !- u --- ------ -----------------------------------------------%------------- -------(Owner and/or Contractor) By:---------------------------------II-..----------- '-------------------------------------------------------------------------------(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 :;1 APPLICATION ACCEPTED B.Y------------- ---------------------------------- -------------- ------------------ DATE-------- 1 - REVIEWED BY-------------------------(---------------------------------------------------� . fes- f •-�. ----- • ------------------------------------ DATE------------------ -•--•----- ------------------------------- BUILDING PERMIT ISSUED-1-----------------------------------------------------------------------------------•----------- DATE-------------------- Alterations and/or recommendations-------------•- -------------------------------- •---------------------------•----•--------------------------•-•----------------.---.......------------------- ------------------------------------------------------------- -----------------------------------------------•---- --------------------------------------------------------------------------- --•--•---------------------------------------------------•- ------------------------------------------------------------------------------------- 1M .i1 --------- •--------------------------------------------------------------------------- ------------------------------------------------------------ -------------------- ----------- FINAL INSPECTION BY--- ----------- ---------- Date-------/Z)-- 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 �0-52 Revised W-2100 it