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APPLICATION FOR SANITATION`PERMIT Permit No. _ (Complete in Duplicate) Date Issued --- ---d. �__� Applicaa-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 w��itt.h��Couu�dnty Ordinance No. 549, JOB ADDRESS AND LOCATION_2% .-- 1_,9d_x_---1:711 _Ae_--------- 4 --------•------------ -------------------------------------------- Phone____ --- Owner's Owners Name-- Address-----7-f--�°�--- ��----`�-------- - - - - -*---------------------------------------------------------------.......-------------------------------------------------------------------- Contractor's Name---,. - ------Aft -_-Ja, ------------------------------------------- 1<------•------------------ Phone-2vir-d----f�� , Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer ourt ❑ Motel ❑ Other ❑ OF Number of living units: -�___ Number of bedrooms _ _ Number of baths __ --- Lot size ---_--SO.-X ISD ---- --- ------------------------------ Water Supply: Public system [[Community system ❑ Private ❑ Depth to Water Table __46ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ { Previous Application Made: Yes ❑ No 99"" New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , I? ' r � I i i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tano: Distance from nearest -Distance from foundation_../��---------material,------------------------------------------------ No. of compartmenfs...'o2 ..._...._..Size4X__Xy0_X-f v __Liquid depth______ .?-.._-__.___Capacity___ Disposal F, id: Distance from nearest well_460.____.Distance from foundation �0........_.Distance to nearest lot line--------�5- Number of lines----------------------------------- Length of each line_-_4/d'-----r----------Width of french----- ----.----------.-- Type of filter material- ------Depth of filter --------Total length--------_ `__•_--_____..-_--_---- Seep^agee it: Distance to nearest well _'_ .......Distance froin"Ifounclation_-__:;� ..._...Distance to nearest lot line__�4------ - s -* i.#,. Number of pits----------------------Lining material:__._.__. _ � � --------Size: Diameter-----��-�---------Deptn-----��-------------------------- Cesspqol: Distance from nearest well-_________-_____'Distance fro foundation..-------`_----------Lining material-------------------------------------- ❑ Size: Diameter--- ----------------------------- ---Depth-----=-----I---------------------------- ------_Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------------I---------Distance from nearest building-_-_.---_-.--..----.---___ ❑ Distance to nearest lot jine------------------------------------- ---------------=------------- -------------------------------- Remodeling and/or repairing (describe):__ ----------------------------------------�---- -------------4---------------------•-•---- ...----...---•-----------•--------------- --------------------------------------------------------------------------•--•-------------------------------•---------------TM- ----------- ---- -- -- - i 1 -------------------------- -----------------------------------.; -----------•--------- c ------•--------Z-----------------:--:-•--•--------•----------------------------•----------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and f rules and regulations of the San Joaquin Local Health District.., ee, Co rC�•C1f C.C/ LC.- �{O ner and/or Contractor) ------------ (Signed, -----------;(Signed}-- r a - .L By:. _. (Plot plan, showing size of lot, location of system in relation to wells, buildin s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------- 1 .. DATE 3 - ------ REVIEWEDBY----------------------------------------- --- ---- ----------------------------------------------------------------- -------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------.------------------------------------------ DATE-------------------- -----------•--•-------- ------------ Alterationsand/or recommend ations------------------------------------------------------------------I----------------------------------------------------------------------------------•---------- -------•--------------------------------------------- ---------------------- -----------------•------------------------------------•-------------------------•----•--•------------------------------------------------•--- - --------------------------•-------------------------------------------- ------- --- - --------------------- - - y FINAL INSPECTIONBY:....... -•---------------- Date----- - V --------------------------------- 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 E5-9-2M Revised W-2100 ;