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mo APPLICATION FOR SANITATION PERMIT Permit No. _ (Complete in Duplicate) Date Issued ti-( -4 C71 2,00-1 & Applica*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 with County Ordinance No. 549. JOB ADDRESS AND OC N. - �r � ^I� --- -------- �Z -------------- Owner's Na a Phone--•l= f • r Address--- - ---------- - -------- ------------------------------------------------------------------ -•----------------------•----------------•-- Contracor's Name- -- ---- . --- . •---- --------------•------------------------ ------ Phone. Installation will serve: Resi encex Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/--- Number of bedrooms — _ Number of baths --/--_ Lot size .--- r ------------- Water Supply: Public system ❑ Community system ❑ Private)K Depth to Water TableA4_7ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam I] Clay ❑ AdobP_PK Hardpan ❑ Previous Application Made: Yes ❑ N New Construction: Yes4 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well-----------------Distance from foundation--------------------Material-----------------__--____--------.-----------. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposa F-el Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--_--__.-.--.---- . Number of lines-----------------------------------Length of each line-------------_.---------------Width of french----------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length----------------------•----------------.-- Seepage Distance to nearest well ��--------Distance f m fou ation_,,,&--.__---..Distance,to nearest lot line.---S Number of its_____-_ --Linin material- -__ - ----Size: Diameter--- Depth-- -- '_ _` _ p 9 Cesspool: Distance from nearest well-------------_---Distance from foundation--------------------Lining material------------------------------- ------ ❑ Size: Diameter--------------------------- ---------Depth------------------------------ --- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well.-.------- -----------------------------------_--Distance from nearest building.--------------_____---_--_--.----------. A ❑ Distance to nearest lot line_-______------------------------ --- --_----- ------- Remodeling and/or repairing (describe):__------ . ---- :,a.- ---•-------- ---------- --•------------------------------------------------------------------------ -•---- ------------------------------------------------------------------------------------------------------------------------------------------•------------ -- ------ A -------------------------------------------------------------------------------••----------------------------------------••-- ------------------------ ------ t�+ ----------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws, and r les and tions of the San Joaquin Local Health District. (Signed)--- ------- --------------------------------- - - Own and or Contrae+osl By:------------------ _--------------------------------------------------------------------------------------(Title . ------ �si (Plot plan, showing a of (o+, ocat'on of system in relation to wells, buildings, etc., can be ed on rev FOR DEPA RTMENT USE ONLY APPLICATION ACCEPTED BY-----------------------F eY DATE r � #._:-SREVIEWED BY--------------------------------------------- -- 1---� ------------------------------ ------------------------------ DATE ----------------------- BUILDINGPERMIT ISSUED---*--------------------' ------------------------------------------------- ---------------------- DATE-------------------------------------------------------------- Alterations and/or recommendations:---------_.- �--------------- -•----------------•----------------------------------•-------------•-- --------------------------- -----------------------------------------------------------------------------.----------------------------•-------------- ----------•--------------------------------------------•---------- ---------------------------------------------------------------------------------------------------•--•----------------- ---------------------•---------- ---------------- ----•---------- ----------------------------------- FINAL INSPECTION BY:----------___________•- -- Date-------_C1--- --- "J V --- --- --- ------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100