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p APPLICATION FOR SANITATION PERMIT Permit No. ;W,3____q___9_ (Complete in Duplicate) I .., Date Issued Application is hereby made to the Sah-Joaquin Local Health District for a permit to construct and install the work herein described. ; This application is made in compliance with County O�dinancg No. 549. J JOB ADDRESS A LOCATION I- �o ------ - ---------"------""=v- - `- '--------------------------------------------------A---=--F----------- a p Owner's Name-,--'-J-� j------ ---------- ---� -• ------------ ---- -- --------- -- - - -- ------------------------------------------------- Phone-!_u---Q- ---�--�r-------- Address----- -`t""T '---------------------------------•------••-------------------------------------------------------------------- Contractor's Name-------- --- -- -- ------'--- ------------------------------------------------------------------------------------------------------------ Phone-------------------------------- Instailafion will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑/ Mot 2---2--- __,[_ Motel E] Other ❑ I Number of living units: ___ __ umber of'bedrooms _ Number of baths ___ Lot size __f7- lV __x---- ______________ Water Supply: Public system [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 �rdpan F]Previous Application Made: Yes ❑ Na 1Q` New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.). SepticTank: Distance from nearest well_________________Distance from foundation--------------------Material---------------------------------------------- ❑, No. of compartments--------------------------Size--------------------------------Liquid depth---------------- ---------Capacity-----------------------Q Disposal Field: Distance from nearest well_________________Distance from foundation----------------._.Distance to nearest lot line_______________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench_-___-_------------__--__-.--_--__= Type of filter material-------------------------Depth of filter material------------------ Total length_______________________________�_ Seepa it: Distance to nearest well____________----------Distance, fro "foundation___A5_I)_____.Distanc? to near telo1line__ 1 G/r Number of pits____________________Lining material____%-�--- ize: Diameter------- Depth----- --_6_'1NP� 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 Sot line-------------------------------------------- ----------------------------------------------------------------------------------------------- l• Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------- -------------------------••------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------- 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. r (Signed) ' ( 9 �---- _---- --- -- ----- ---Q�►�-- ;`�'`i='�./----------�-----------------------------------------------------------------{Owner and/or Contractor By:---- ---- • ---------------- -- -- --(Title)--------- (Plot plan, showing size of lot, location of system in rLlation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13" - ------ ---------------- ------------------------- ---------------------------------------- DATE--'_ ------------------------------------------------------ REVIEWED BY------------------------------- ------ ------------------------------------------------------------ ------------ DATE-------- .- ,�' --------------------- ------------- -- - BUILDING - - BUILDING PERMIT ISSUED------------- - ----------------------------------------------------------------------------------- DATE----- ------------------------------------------- Alterations -- - ------------------ Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------1!777�--•-•------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------•------------------------ ------------------------------------------------------------------ -------------------------------------------------------------------- -------------------------- ------------------------------------------------------- - _------------------------------------------------ FINAL INSPECTION BY------------------fI---------t-`------------------------------ D .- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100