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n APPLICATION FOR SANITATION PERMIT Permit No. --------------- ' (Complete in Duplicate) Date Issued 4Ar,plica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Ths application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND O TION °"` �x�."M --- /t1 - rZ �� --=1� ----------------- -------- Owner's # Owners Name •- ---------- . -------------•---------------------- ----------------------------------------- Phone ----`�� Address-------- / - -- --- - ---------'�----------------------•-----------------------••------------------...--------•----- ------------------------------- Contractor's Name_____f_,_P- ----IP - ---`------ ----`-- - '-----•-------------------•--•----------------•--- Phone--416_._ -------- r ,7--. Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _l_____ Number of bedrooms ___7—Number.of baths ___J___ Lot size -------/_1? --_______________ Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table .1'5_ ft. Character of soil to a depth'of 3 feet: Sand_Ej -Gravel ❑ Sandy Loam ®- Clay Loam ❑, Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes E❑ No Z . New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu jirp ewer is-available within 200 feet.) Dafrom nareswell __ _Distance from foundation---- Material_r_ ___ � e ------- Septic Tank: snce ? No. of compartments-------2--------- -----Size---.-4 1r X . r:---Liquid dep h------ --------Capacity----�9--a-4---------- Disposal Field: Distance from nearest well__-,5.___b_ -.-Distance from foundation_____4� 0-1______-Distance to nearest lot line-_-_�__..._ Number of lines------------ ---- -r ---------_ of filter material------ length______/ ngth of each line-------/--/�------------Width of trench------- ------------------ Type of filter material____ e th .. /Q.________��______f�___ p : --------------•-- F See} age Pit: Distance to nearest well_____-------------------Distance from foundation____________....___.Distance to nearest lot► ine_________________ Number m -----------------=----Size: Diameter-:-------:---------__---Depth--------------------------------- s ❑ - Cesspool: Distance from nearest weil-----------------Distance from foundation--------------------Lining material------.________________________---._ -, _1__ _Size:,Diameterc - = Depth---- --------------------------._Liquid .Capacity----- •---•-----------gals.� Pri ❑ r.c _ � . Distance from nearest well-________ --------------------------------------Distance from nearest building_____________.___ __-.___________._. "Y� ❑ Distance'to nearest lot line-----------------------------------------------•-----•--------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------- ---------------------------------••--------•----------------------------------------••----------------------------•-- -----------------•------- ------------••------------------••------------------------------------------------------------------------------------------••---------------------------•------------------------•-•---------•--•---•----•------------------- � .T I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, end'rules and regulations of the San Joaquin Local Health District. r .! ---- -----------------------------------------------------(Owner and/or Contractor) (Signed) _ --------------(Titie)---- ------------ _ ----------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------- --------------------------------------------------------- DATE------------------•---------------------------------------- REVIEWEDBY----------------------=--------- ----------------------------------- ---------------------------------------------------------- DATE-----------------------------------•--•-------------------- BUILDINGPERMIT ISSUED-=---------------------•-----------------------------------------------------------------------------• DATE---------------.------------------------------ ---------• Alt r tions,and/or recon mendations: -------------------------- -- -------------------------------------------W------'.....0 r..: t=` �•- � .E -4t-l= 1`�`tit�i�F-tel$ /-------------------- -------------------- '� -�p"+'--- ------------t-' .r ....y: ..,,1 •��,��`�= - .�:.-.�_��-- --'�iE.�_�4�°=•� -=-4---�� x�'._� _�__.'. ' �� ;.,�/ -------------------- ---------- • •-------------------------- -----------------------------•---- -------------------------------------------------- --------------------------------------- ------------- --------------------------------------- -------------------- - - ----------- - -------------- ----------------••---------••---------------------------------------- -------- ---- ----� FINAL INSPECTION BY:---- ------------- •---------------- Date--- - --- ------ ------------------ ' ----------- SAN JOAQUIN LOCAL HEALTHDISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 4, ES-4-2M ; Revised W-21,00