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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ,5 Date.Issued Applica+ion is hereby madA tFfen quip Local Health District for a permit to construct and install the work herein described. This application is made in compliance wwil h County Ordinance Ng--4'1. - JOB ADDRESS AND LOCATION T l` `5' ----------------------------------- I-------- ---- Owner's Name----------------------Jy4E .-----------/--;-;0-2�>O- --/�--- - - ------------------------------------- Phone:----------------------------------- ' Address ---------------------•----•---------•- -----------------------------------------------•------------- ------...._..-------------- Contractor's Name------------------- ---------------------------------------------------- •------------- Phone----------------------------------- -----------•-------------------------------------------------------••--- Installation will serve: Residence e-rtment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living unifs:,3_ Number of bedrooms__ Number of baths -._. Lot size ------/�,. __ Wafer Supply: Public system-❑ Community system -E],-- Private'P4--te`pth to Water TableT____:__ ft. Character of soil to a depth of 3 fest: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeAQ_Ha ydpan E Previous Application Made: Yes ❑ No ew Construction: Yes , 40-0' , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' n. y .. Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- El ___________._'_______---- ..________.______._.❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line________`_______ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- lj .�.., Type of filter material------------------------'Depth of filter material---.-------------'-----Total length-------------------------------------.---- r, Seepage Pit: ' Distance to nearest well___ _-__..______._Distance from foundation--------------------Distance to nearest lot line_-__-------_--_-- ❑ Number of pits-----------------------Lining material-----------------------Size: Diameter------------- --------.Depth----------------------•---------- Cesspoonearest'-well Distance from neareswell_________________Distance from foundation--------------------Lining material--------------------------------------- V1 Size: Diameter----.-.-r---------------- ---------De th----------------- -------------------- -___Li uid' Capacity ❑ ---- p - - q ----------------------------gals. Priv Distance from`nearest welf___________r�_____ -____ isfance from nearest building_______� _ �------- Priv - Distance to nearesfllot-line-------- ------------------------� ---------------'------- --------------------------------------------------------- Remodeling and/or repairing (describe)--- ------ ---------------------------------------------------------------------------------------- ------------------------------ k s A -------------------------------------------------------------•-----------------•--------------------------------------------------------------------------------•---------------•-------'----------------------------------- I hereby certify that 1 have prepared•fhis-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. 1 i - (Signed)--------------------------------------- j ------- --- �------------------------------------------------(Owner and/or Contractor) By:. ----=--=----------------------------- --------••----------------------------------Mile)--------------------------------------------------------------- (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------------------ ------------- ------ --43--------------------------------------------- DATE---------- I - ----------- REVIEWEDBY----------------------------------- ------=-- --------------------------------- --------------------------------------------- DATE-------- •-------._...-.•-----....-- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------'--------------------------------------------------------------------------------------------- ----------------------------------------------------•--------------=---------------------------------------- --------------------------------:------------------------------------------------------------------ 3 ----------------------------------------------•----•---•-----------------------------!---------------------------------------------------------------------------------------------------------------------------------------- x ' -------------------------------------=-------------------------------•-------•------------------------------I----------------- ------- -----------------------------------------------------------------•-------------------- FINAL INSPECTION 'BY:. "---------��--Y&------------------ ------ Date--- ------------ .- 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 ; Revised W2100