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r _ APPjPLICATION FOR SANITATION PERMIT Permit N9.' _______________-------_ G} '" 2- (Complete in Duplicate) 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. " JOS ADDRESS AND LOCATION---- -- "10 ----- - , ;__._rcA____ . 9 -------------------------------- -------- --- Owner's Name--------------------------------- e , " + ------- -------- --- - ------------------------------------ Phone----------------------------------- Address----- -------------------------------...Address--------------- _ ----- -------- ^- -- -- -��---------._---------- Contractor's Name - '� '�� '< -- �-�!-'�------- -------------- --- 1 9 --- - --------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ . Motel ❑ Other - Number of living unitsd4_____ umber of bedrooms. --- Number of baths�____ Lot size ---------, �_a--,x__,f�_----------------------- -'"""-""-"""-"-- Water Supply: Publics stem �' Community system Private Depth to Water Table ...._.._ ft. Character of soil to a depth of 3 feet: Sand ❑' Gravel ❑ Sandy Loam ❑ lay Loam ❑ Clay ❑ Adobe EjHardpan E] Previous Application Made: Yes ❑ No U61 New Construction: Yes' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sew is available within 200 feet.) f -- Septic Tank: Distance from nearest well_ ____ ____ _Distance from foundation___ _.Material_-_-___---____________________-_____..__.______. r�n 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----------------------------------- - Type of filter material-------------------------Depth of filter material---_----------._-------Total - length---------------_-------------------------- _____Distance om foundation.-/ A Seepage'Pit: Distance to nearest well_____________' /_ -...__:Distance to nearest lot line __ Number of pits-- _-Lining Lining materialtiSize: Diameter________________.Depth______--�_________ Z! � 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--------------------------------------- El __-_ --_______________._..___-.__-_-. Distance to nearest lot line------- ------/-"I----- � �f ;------ -------------------- Remodeling - --------------------Remodeling and/or repairing (describe)_________________________ _'__ - ._____------ __/�__ _..-F .. ! ------------------------------=----------------------------------------------------------- , ----------------------------------• ....... ..... = - -------------------------------------------------------- •-------------------------------------- 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 r gula+ions of the San Joaquin Local He +h District. ---------------/ � .... . kr {Signed) ' (Own /or ntractor) �` "</ - --------------- Title In-41------------- (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-------------------- - -- ---------------------- ------------ ---------------------- -------- DATE.""----------. REVIEWEDBY------------------------------------------------ -- -- ---------------------------------------------------------------------- DATE - BUILDING PERMIT ISSUED------------- a -A---------.DAT -------------- A A - Altedos d/or . - reccnmdati ns: -- � - - kk ------ -_-- ____________________________T___ _______-_________________y-'__...__-�.___ --------------"""""""-"-""""""""--"._""""-----""-"----"--""""""----"""------------------------_-------"""--_---""""""""-""""---""------"----------------.--.""-"""--____"------_------ --__--------__"-___"-"------- FINAL INSPECTION BY:---------- k ''---------------=----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street } Stockfon, California Lodi, California Manteca, California Tracy, California t ES-9-2M 8-5{ Revised W-2100