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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) r 7� Date Issued '� Applica{ion is hereby made to the San`Joaquin Local Health District for a permit to construct and install the wo rein described. k This application is made in compliance with County rdinanoe No. 549, JOB ADDRESS AJAD LOCATI N__ ----- ----- ..� r '---------------- -- ----------------- ----- Owner's Name__.._ . -------- - - 1 -- ,.. ---- ------- Phone Address------------ ----- - - t w '( Contractor's Name--•------- ------ ------------------------------- Phone---------------- Installation will serve: Residence [Apartment House ❑ Commercial Trailer Court Motel JJ ❑ ❑ ❑ Other ❑ Number of living units: __-11• `Number of bedrooms �iA ` nn Number of baths .- ___-- Lot size --- 1-1y, - -1�-,_ - -- --r�.--------- Water Supply: Public system'`[R Community system ElPrivate'❑` Depth to Water Table -------- ft. f< Character of soil to a depth of 3 fee+: 'Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[] Hardpan ❑ i Previous Application'Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ �- TYPE OF INSTALLATION AND SPECIFICATIONS: jk (No septic tank or cesspool permitted 'f public sewer is available within 200 feet.)( f - . I.. /I nn Septic ank: Distance from nearest weH_ _. istarlc fro (foun ion_.-_!-Lf__._.__._.Materia_ C i 1 No. of compartments Sill- �rr� �''"---Liquid �de�p�th--- -----'� Capacity-_--, apacity----------------------- p DisposalField: Distance from nearest well_ Uistance from foundation�_�_.!� '--Distance to nearest lot lie - f 7 ij Number of lines____:i___ _ _____ ___.__ .__Length of each line------____- Width of french------_Z- Type of filter matena!_ 'Depth of filter materia -------------------Total length-------------� �i�_p---------_____ Seepage Pit:= Distance to'nearest well`` ----- -------- from foundation_____________ __:Distance to nearest lot line_______.________- . i � i ❑ Number of pits ' - Lining material---i---------. --w--Size: Diameter_-•------------------Depth--- ------- f_�_ J R -- Cesspool: Distance from nearest well-----------------Distance from,founda''tio'n_"------ ____ Lining material-------------------------------------- Size: ____ .____._____.__ -_-Size: Diameter------- (-- --------------------- ----Depth------------------------------------------- Liquid CapadtY gals. m y . ; -- Priv ' `'Distance from nearest well___________________ __________Distance from nearest building � _ g ------- ------- ❑ - Distance to-nearest lot line_____________________________ ---- e ----------------------------•------------------ Remodeling and/or repairing (describe) ----------------- -----------••----------------------•----••-------•---------..-------•-------..- --•-----------------------•---------•--•-------•---••--------•---•--------•----------- ------.---------------•---------•- ------•--------------------•--- ----------•------------ ------•-•--------------------------------- ------ --------------------------------------------------------------------- ----------------------------------•--------------------•----------•------------ - --------------•---------------------- I herebycertify 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. ---------- -----------I------------------- (Owner and/or Cont ttorj ----------------------- ------------ By:---------------------=--- --------------•---------�---------------------------------------------------------------------------------(Tit le)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). Y.I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y- =_ --------------- ------ ------------------ ------ DATE (- , REVIEWED BY------------- ---------------- DATE- • ------------- - BUILDING PERMIT ISSUED----------�. -.-------- - ----------------------------------- DATE------- Alterations a d/or recommendafions:---------------------------^�-------------------- '-------- 't . _______________ ------------------------ _ ______________ ______-------___-------------------------------------------- ------------- --------------------- ----------------------- -- __________________________________________________________ _ • q FINAL INSPECTION-BY:------------ == '. .Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+roe} 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100 \"/,