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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -_____QV-7-IS-)-- 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 Co�ugnty Ordinance No. 549, JOB ADDRESS AND LOCATIO,/N�_ -rt,41-L_____________ Owner's Name--- Com' ---------------------- - --------------------- -------------------------------------- Phone '"..t"__Iff- ------ Address ±-. . ------..... � —----- ! ----- ------------------------------•------------------------------------------------------------------------- Contractor's -------------------------------------------------------------- Phone.-9�--``!"--4-0-��-a------- i Installation will serve: Residence ❑ Apartment House ❑ Commercial Z—Trailer Court ❑ Motel ❑ Other ❑ j Number of living units: __ Number of bedrooms __I -- Number of baths __L, Lot size �_ Water,Supply: Public system IV Community system ❑ Private ❑ Depth to Water Table _4�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeD( Hardpan ❑ Previous Applica+ion Made: Yes ❑ No X New Construction: Yes ❑ Nox TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------------------------------%4 No. of compartments--------------------------Size------------°-------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: 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----------------------------- - ------ Seepa e Pit: Distance to nearest well-. `oma.-t—,Distance from foundation------ 4-------.Distance to nearest lot line_A�-�--'_" Number of pits____.__----------Lining material__�__AW-Size: Diameter____lk-��__-.Depth--- --4-b___________________ Cesspool: Distance from nearest well-----------------Distance from foondation----------.---------Lining material__________-_______________----__ ❑ Size: Diameter--------------------------------------Depth----•----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------._____- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------- -- Remodelin and/or repairing describe :_ _ .......................... ___________________________________________________________________________________________________________________________________________________________________________________ _______________________________ ----------------------_____--------------------------------------..---------------_-----------------------------------------------------------------------------------------.----___-________ I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ------------------------ -------------------------------�/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). 3 FOR DEPARTMENT USE ONLY ) APPLICATION ACCEPTED BY- - --=---=----------------------------------------- - ------------------------------------- -- DAT E--c: BY -- --- -------- ------------------ DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------4, t Altera+ions and/or recommendations-------------------------------------- ------- --------------------•------------------------------------------- -------------------•---------------------------------------------------------------------------------:------------------------------------------------------------------------------------------------.-_------------------- ------- - -- ------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------- ---=- ------ - - -------------------------------------==---------------------------------------------------- ----------- -•------------------------------------------------------------------------------------------------------- M P 11g- _ --- -------------- -- --- ._ � --------_ ----------------------------•---- FINAL INSPECTION BY:_________------- Date_ -- -_-- I SAN JOAQUIN LOCAL HEALTH DISTRICT 4 130 South American Street _ 300 West Oak Streef 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8.51 Revised W-2100 i