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APPLICATION POR. SANITATION .PERMIT Permit No. O — -' } f41� (Complete in Duplicate)3 Date Issued I . 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 Ordinancla-Ub. 549. .o JOB ADDRESS AID LOCATION.- --- - -- ----- --- ,- ----__ --- Owner's Name____- 1-- - Phone . ----- 9 - - _ ------------ - ----- -- Address---4 .�. .a.� 4 _.:-=--[�---------------------------- Contractor's Name---- F.. ------------------------- ------ ----------------------------------------`------------------'- Phone.--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ otelI❑ Other 4 Number of living' units: .xComrftunity umber of bedrooms . _`Number of baths ' Lot`ize _________ ___-_:I-_I1_ _______________.__.__ 1. Water Supply: Public pstem system ❑. Pr.-ivate ❑ 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 Mede: Yes ❑ No New Construction. Yes No ❑ TYPE OF INSTALLATILNAND SPECIFICATIONS:(No septic tankspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well____.�77Distance from foundation--------------------Material------------------------------------------------- ❑ No. of compartments- -------.--Size--------------------------------Liquid depth------------------------.-Capacity---•------------------- v" Disposal Field: Distance from nearest well------------------Distance from foundation---------------------Distance to nearest lot line----------------- 1 ______ L El Number of lines-------------------------------- Length of each line------------------------------Width of french.-----_--------------.-.----------- Type or filter material_________________________Depth of filter material-----------.-----------Total length------------------------------------------ Seepage Pit: Distance to nearest well-----------------------Distance from foundation----.-------........Distance to nearest lot line------.__________ ❑ Number of pits---------------------Lining material--------------.---..__.Size: Diameter-----------------------Depth- ------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation---.------ ------- material________ ___--______________.______El . Size: Diameter___------------------- De th______ __----------------------------------------- _Li uid Ca acit gals: `� - p Privy: Distance from nearest well_ __. ___.______-_Distance from nearest building-_�� ----------- -----_ - _, ------ -- Distance to nearest lot line------ / -------------------------•--------------------- .� I -- Remodeling and/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. S to ws, and rules and regulations of the San Joaquin Local Health District. Si ned A ( 9 } = -- ---------' Owner and or Contractor By:-------------------------- - Title ------------------------------- .. f (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION(ACCEPTED BY>'C -------------------------------------------------------------------------------------------- DAT -- ------ - -- - REVIEWED BYE ' > -�JD, ' - =-------------------------------------- DATE - ,._ BUILDING PERMIT"ISSUED i------ )--------------------------------------------------------------•---- DATE --------- U--------------- -- Alterations and/or -k"'commend Wofas ---------------------------------------------------------------•--------------------------------- L _____________________________________---------•--------.-------------------------------------------------.------.-------.--------.-------------------------------------------------------------------------------------------- -------------------------- ` f !F FINAL INSPECTION BY:..------- --------- --- ----------------------------------- Date_...----- ...... - -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" SfreefI Stockton, California Lodi, California Manteca, California Tracy, California li _ r ES-9-2M I0-52 Revised W-2100 i