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i• II _ APPLICATION FOR SANITATION PERMIT Permit No.._�.. (Complete in- Duplicate) 1 � Date Issued L�Applica�ion 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 LO ATI N--------=----- _ -v------ ---I-`-----------------------------=----------------------------• ----------------------------------------------=---------- Owner's Name --------------------------------- -- Phone _ -r�*-- �- ------ -----------�-•-.- - --- Address__ d Q c$.- •� ------------------------ -- ------•---------------------------------- - - r Contractor's Name---- ' ��'` r r----------- ------------- Phone--�S---.E Installation will serve: Residence [�partment House. ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 6_ Number of living units: ___- Number of bedrooms ---•'°�_ Number of baths—Lot size :__'�______________________ t ( 1 Water Supply: Public .ssystelm EsCommunity system ❑ Private ❑. Depth to Water'Table�a_�_�`_ ft. Character of soil to a depth;,of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [a -"Hardpan ❑ r Previous Application Made:,I�Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS:, ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) { 0epl;-Tan,k: Distance' from nearest well ----------------- Distance from foundation ________-.___c___. Material ------------------------__----- --- ------------ No. of cbmparfinents---------- ---------40Aize.......... ............... --_,-_-Liquid depth------------- - ------- Capacity ----------------------- w I isp.tal ield: Distancellfrom nearest well_...._.._-Distance`from foundation___�d--_______.Distance to nearest lot line ___S_.._ Number.11of lines _:_.:_'____._/-__________________Length of each line ___..__--------------- Width of french ------ �Z___`�_C__��----------------- Type of'filter material_____S�`kkC�____Depth of filter,material------ �g_....______.Total length_____ _________________________ Seepage Pit: Distance to nearest weII Q. ' 1___Distance from foundation_____;..v-.Distance to nearest lot line ___'©_--__ Numberl,of its ------ ------------Linin material__ /._ ffGl .Size: Diameter- Q.4__ *-------Depth--- --------------------- P-, g Cesspool: Distance from nearest well_________________Disttance from foundation -_==------------___-Liquid Capacity material ity-._________ p 5�ze: Diameter ------ --- - ------ - --- -- Dept h ------------ -----------------gals. Privy: Distance from rearest well ____------------------------------------------- --Distance from nearest'bijilding --------------------------------------- ElDistance to nearest lot lire ------------ -------------------------- ------------------------------------ ..._..------..----------------------------------.-•-------------------- Remodeling and/or repairing (describe)______________________________________ __ •____ ------------------------------- -------------------------4------------ ---------------------------------•-------•--------------•---------------------------------------•-•---------------------------------- -------------------------------------- --------------- I hereby certify that I have prepared this application and that the work will -be -done in accordance with San Joaquin County ordinances,S.ta laws, and rules and regulations of the San Joaquin Local Health District. Z a ! I vIC 1,. r Contractor' (Signed) ----- .... -- •--a" 4_1 By:.....-- :d.'- �� '�} f... -------------- ITitle} �S -A _� "`-F-e.^s-------- . (Plot plan, showing size of lot,locafion of system in relation to wells, buildings, etc., can ,be placed on reverse side). - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------- --- DATE------ 1 REVIEWEDBY--------------------------------------------- ------ - ----- --- - --------------------------------------- DATE----------- ---------------------- -------------------- BUILDING PERMIT ISSUED! --------4 "--------------•----------•------------------_---__---__ DATE --------------•----------J�,----------------------------------------- ------ and/or recommendations:- }-----t-- = ----�----;- __=__t- ------- _.. --- =----=----- = ->,- -------------------------------•--------------'l ---- -------------------------------------------------------------------------------------------------------------- ......... ----------------------------------- '1, Il' II ------------------------------------------------------ _______________________________----------------------------------------- .------- - ____.. _.-°.�.____I___:___.____.._-.---___.---------------------------------------- 1 FINAL INSPECTION -BY: - .__ '�---------------------------- Date --------- `-�-�- -------------- SAN f---------- SAN JOAQUIN LOCAL HEALTH DISTRICT II 130 South American Street 300 West Oak Street y132 Sycamore Street 814 North "C" Street Stockton, California ;I Lodi, California "i— Manteca California Tracy, California ES -9-2M Revised W-21,00 �1 Q