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i ' APPLICATION FOR SANITATION PERMIT Permit No. __z_'�__ p (Complete in Duplicate) 7 8 d 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. I i%� �7 �-_- j_r-- JOB ADDRESS ANA LOCATION ! r ----------------------------------------------------------------------------------- I� � Owner's Name------ �'C� ------------------ Phone s 'c Address------ -----• ,------------------------------------------------- Contractor's Name------------------------=---------- ------ ---------------------------------------------------- ---------------------------------------- Phone-------------------------------- Installation will serve: Reside nc e rApartment House ❑ Commercial E] Trailer Court E] Motel E] Other E]Number of living units:'-/--- Number of bedrooms __.--),Number of baths ___/_ Lot size __ __ ___ . _ ------------- Water Supply: Public system Community.system ❑ Private E] Depth to Water Table -______ ft. + Character of soil to a depth of 3 eet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobellk Hardpan ❑ f Previous Application Made: Yes No ❑ New Construction: Y>110 No ❑ 3 TYPE OF INSTALLATION AND SPECIFICATIONS: 9 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) C Septic k: Distance from nearest well----------"- ------Distance from foundation----!Q---------Material________ _____ -- No. of compartmeits________" ______Size___ __ _ "Liquid depth_______ --__________Capacity----4 ______� " Disposal Medd` Distance from nearest well----__---------Distance from foundation____---0----------Distance to nearest lot line___ ________ Number of.lines-------------/-------------__ ____Length of each line________d_2- r______.Width of french------- ______________ Type of filter material__l_'_+!1-Y- _Depth of filter material---_ ( {l________._-Total length------- ------------------ Seepage Pit: Distance to nearest we'll-----------------.____Distance from,foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-------:=--------------Size: Diameter------------------------Depth--------------------------------- Cesspool: ------ -----Cesspool: Distance from nearest well--------____-----Distance from foundation--------------------Lining material_________---_____--_---______________ ❑ Size: Diameter------------------- ------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---_____-----------------------------------------Distance from nearest bu4ding------------------------------------------ F1 Distance to nearest lot-line--- ---------------------------------------rl-------------------------------------- -----------•--------------------•- ------------------ Remodeling and/or repairing (describe):------- ---•--------•-------------------------------------------•----•--------------------------------------•- ------------------------------------------------------------------•-•---------------------------------- ---•-------------------------------------•---------------------•----•- •-•.........---......-----•-------------------••--------•---------•----------------=-----•------------•----------------••-------- _ 1 ---------•-------------------- -------------.... -------------------------------------------------------_---------•-------------------------------------•---------------------------•------------------------ I hereby certify that I have prepared this applicaion and that the work will be done in accordance with San Joaquin County d ordinances. State laws, and rules and regulations o a San Joaquin Local Health District. a< (Signed) -------- �i - ----------------------------------------------------------------------(Owner and/or.Contractor) ----------------------------------------------------------------------------------------------------------------------(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 i APPLICATION ACCEPTED BY-----------' /-�f-f �/ --------------- --------------- DATE----- - -- - --------- - "�- d• REVIEWED BY---------------------------------------- ------------------------------ -- - - -- - - --- -- ------------------ - ------------ DATE----- -------- � `^�-------- -- -- BUILDING PERMIT ISSUED-------•------- ----------------------------•-------------------- ------------------- DATE------- ----------•------------------------ Alterations and/or recommendations-------------------------------------------------------------------------- ------------ ------------------------------------------------------------------- f __________________________________________________________ _____F--_-___----___-.__-_-____________._______________________________________________________.____.___.__________------____________________________-.-_____._ ____________________________________________._____-__-___________.__________._______________.______...__.______________._____________--___-_------_-_-----_-.__-__-____________________________-_____-_-e:�------------------- ------------------------------------_______.____-_______-__._-_-____,_--_-.-____--.._..._______ ______________------------------------------------------------ ---------------- ----.----------_____-_________________-- 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 8-51 Revised W-2100 'a