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APPLICATION FOR SANITATION PERMIT Permit ..1 17 (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 Or-dinance No. 549. JOB ADDRESS AND OCATION/=_G_�__~_Q_--- -.---. '-�j±__V1rC ,- t � ------ - ----------------- Owner's Name•--- -•-•••. I Phon _ Address...................... �--iZ--- -•- 1. tJ��'kt.�f�- - - -. ---------------- Contractor's Name -- -- ------- - Phone-------•-- Installation will serve: Apartment House ❑,,/Commercial ❑ Trailler Court ❑ Motel ❑ Other ❑Number of livinits: -__[-___ Number of bedrooms -_l__. Number of baths ___1___ Lot size ------ �77n `b_0?_______________________ Water Supply: Public system ❑ Community system Or Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No R New Construction: Yes X , No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �+ Septic Tank: Distance from nearest well_� :� Distanc ffodation____-1_ ______.Mater1_ _____ �' _.. 'No. of compartments_________------------Size- Liquid depth___-______'�_-_-_______Capacity.... _ -_-- Disposal . Field: Distance from nearest well_o2Q_C +_Distance from foundation _._�.�_:_-___.Distance to nearest lot line--�____- Number of lines--------]________________________Length of each line------- -0__..17-___-.Width of french------- _____________-_- Type of filter material..___S� Depth of filter material___:__-$----------Total length----------6II______________________ Seepage Pit: Distance to nearest well______----------------Distance from foundation....................Distance to nearest lot line------------_-- 1-71 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------------_--_----••----------- '-s- Cesspool: -sCesspool: 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 lot line----------------------------------------------------------------------- ------------------ --------------------`='7-7--------------- Remodelingand/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 law and rul and egulations of a San Joaquin Local Health District. (Signed) --------------------------------------------------------------- Owner and/or Contractor By:.....................•••--••----•••-••-••••---••-------------•-•-•----•-----------•---------------------------•-•-•----------------(Title)--------- ---------------------------------- ------------------- (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 APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE----------------- /- REVIEWED BY------------------------------------------------- - DATE------...— -_ ---- BUILDING PERMIT ISSUED----------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations-------------- -------------------------..............................................................................................._............... ---------------------------------------------------------------------- --------- ------------------------------------------------------------------------------•-------------------------------------------------------- .................................---------------------------------------------------------------------------------------•---•----------------------------------------------------------------------------------------------- ----------------------------------------------------------•---------------------------------------------------•-------------------------------------------------------------------------------------------------------------- - - --------------------- ------------------------------------ ------ C �- FINAL INSPECTION BY-------------------------) ----------------- 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 10-52 Revised W-2100