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P V APPLICATION FOR SANITATION PERMIT Permit No. .PI (Complete in Duplicate) Date Issued Applicafion is hereby made to the San Joaquin Local Health District for a permit to construct and insfal4 the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATE •- ------- � -'--- --•---••-----------------------------------------•--------------------------------- Owner's ,Name ------ -y------------------------------------------- ------ Prone------/64,7 Address - ---- --• - .... Contractor's Name________________ _ ____ _ ----- -------------------------------------------- Phone.. - Installation will serve: Residence � Apartment se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ -____ Number of bedrooms --- ---- Numb r of baths`_- __ Lo} size .__� ��Q----------------- l 4 Water Supply: Public system Community system ❑ Private ❑ Depth i6 Water Table�Qft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam [❑ Clay Loam ❑ Cloy [] Adobe Hardpan E]Previous Application Made: Yes ❑ NOW New Construction: Y No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.,public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_ Disfance from foundation_ Q__�__-Material.-__ �J—yr�t ,_-___ y yn P i`3--• •_•�{•• Liquid depth_:- / Capacity -' ----�� No. of com artments_ --. -_-Size.. � ✓ Disposal Field: Distance from nearest well________________Distance from foundation_:------------------Distance to nearest lot line___-_____________ ❑ Number or lines----''.____--'---------------------Length of each line-------------W,------------:Width-of french--------------------------- - Type of filter material_______________________Depth of .filter;material--------.-------------- otal length________-_______________-_-----__________- Seepage Pit: Distance to nearest well- -- ------ ---------Distance frpm foun tion_,Z----------Distjnce to nearest lot line-------.1--i----- Number of pits---'-I------ Lining 'material - Size: Diameter---- ----------------.Depth ------------ esspook - Distance from nearest well= _ ----_Distance from foundation--------------------Lining material------------------------------ ------- F1 Size: Diameter--------------------------------- ---{Depth-----------------•------------------- ----------._.Liquid Capacity- --------------------------gals. Privy: . Distance from nearest well_______________________________________ _________Distance from nearest building----------_--._________________-.____. ❑ �... Distance to nearest loft line--- - ----------------------------------------------------=---••-�-------'------------'-------------------------'---------'.�---- Remodeling and/or repairing (describe)--------------- c --------------------•-----•--------------------------•-------------------- J -------------------------------•,--------------------------------+•------------------ ------------------------------------------------------------•-----------------------------------••----------------------------------- -------------------------------------------------------------------------- -----------------------------------------------••------------------------------------------------------------------------ --------------- 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 nd rule d regulaf'of the San Joaquin Local Health District, I (Signed) - ------ ------- - -- =---------- ------------------------------------------------------------- -' ---(Owner and/or Contractor) I By:-------------------=---- --------\-- -------------" ------- Tale ( ' ) - -------- (Plot plan, showing size o , locafion'of s stem in relation to wells, buildings, etc., can I ed on reverse ide). FOR �D_PARTMENT USE ONLY APPLICATION ACCEPTED BY----------- I--- -- -•--------------------------------------------------- DATE-------- ----------------j REVIEWEDBY----------- ------------------------- -------.--------------------------------------------- DATE----------- ------ - -- ---- ------------------ BUILDING PERMIT ISSUED------------------------------------------------=-----------------------------------------•--------._ DATE Alterations and/or recommendafions: �' ------------------------_-- -------------------•-------- -----------••----•-----------•---------------------------------- µ t 1 ---------------------------------------•-------------•---------------------------------------------------------- ------ ' k ____________________________________________________ ___________-_-.--__.___________-.______--_____________-_______-______._______.__________-_____-_-._________.- . 4 � i ______._ _..�. __--------_____________ f S, FINAL INSPECTION BY:-__"" _- 1 ----------------- Date------- .- ---- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M I0-52 Revised W-2100