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� ✓ � -_=�-� APPLICATION FOR SANITATION PERMIT Permit No- (Complete in Duplicate) .ry Date Issued 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 with County Ordinance No, 549. JOBADDRESS AND LOCAT ON-------- k 1 Owner's Name------.--- -- -_ i ---------- ------ Phone----p-��-----/� +� --------------------------------- -- Address-- ---------------•-----------3 3-- Contractor's Name--- _--.-_ -------•---------- ----------------------------------------------------------- ----------- Phone_ - ------------------------------------------------ Installation will serve: Residence f Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Oth-er [:jr Number of living units: _--- Number of bedrooms Number of baths __/--- Lot size ----- -;4---X-- A-Q Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. j Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ` Hardpan E]114Previous Application Made: Yes El No � New Construction: Yes 4 No E] 1` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept Tank: Distance from nearest well �s n rom foundation____ ,� )-------Mater- I___ -' - ---- No. of compartments----------- ---------Size_ _ - _-�--Liquid depth---------' '> Disposal Field: Distance from nearest weir---��.Distance from foundation----- / �� '�� J��ty'f - �____-Distance to nearest lot line--_-- _ --___. Number of fines_____---__ �- ,_'(_Depth Length of each line----___A-0--- - _)_.Width of french----- - �j Type of filter material__ of filter material--------- __---Tota! lengfih____- -Q_________ __ - --------- 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-----------------bistance from foundation--------------------Lining ❑ Size: Diameter--------------------------------------Depth------------------------- -------------------Liquid Capacity---------- ----- --- -----gals. Privy: Distance from nearest well--------- ---------------------------------------Distance from nearest building ❑ Distance to nearest lot line------------------------------------- ------------- --------------- Remodeling and or re ring (dcri:,e)------ f1 _ b ` r - ----- --- --------------------------------------------------------------------------------------- ---------------------------------------------------------------------.--------------------------------------------------------------- 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. t (Signed)____ ! el �: ---------------------------------------------------------------(Owner and/or Contractor) 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___ y - --------------- - - --- --------------------------------- DATE-- �_-.• �--------- ------------ -� ` �. -------------- REVIEWED BY ------- - DATE---------------------------- BUILDING PERMIT ISSUED--. ---------------------------------------------------------------------- DATE Alterations and/or recommendations----------------------- -- ,�'f f h ` . r---- ----- Ij_d----------ot k ---- --------_99 ��---------------- z--- - -- � - --I�, 14 �� _ FINAL INSPECTION BY:---------- -------------- - --- --- Date---------- - -- - ----�- ----------------------=---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 IJorA "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES—'?-2M 8-31 Revised W-2100 `fir