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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / Date issued 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 LOCATION___7 K__ ____ __�--u-- ---______ --�' ,- ----------- -------------- Owner's Name � �CC'ut1 � ------------------------------------------------ ----------------------- P one Contractor's Name �� " PhAo Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _f_____ Number of bedrooms __ . Number of baths _j_____ Lot size ------I__ ' _ -c5,---_____________________________ Water Supply: Public system; Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑' Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from neares# well-_-__----------Distance from foundation____._._____.'__._:Material-----------------------------____________________ ❑ No. of compartments--------------------- _-Size--------------------------------Liquid depfh---------- ---------------Capacity----------------------- Disposal Field: Distance from nearest well__________________Distance from foundation--------------------Distance to nearest lot line—----------- El .- _______❑ Number of lines-----------------------------------Length of each line------------------------------,Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------- Seepage Pit: Distance to nearest well:"�.i_------ -------Distance from foundation__________ _.�.,___ Distance to nearest lot line_____.____.______ v ❑ Number of pi#s----------------------Lining material-----------------------Size: Diameter--------------- ---- Depth-------------------•------------- � Cesspool: Distancevfrom ne rest well__10--------Distance from foundation-- -J_d.------.Lining material___ Size: Diameter , . Depth --1� j Liquid Capacity " gals. Privy: Distance.from nearest well------------------------------------------------Distance from nearest building____._____-__________________.__--__._._. ❑ Distance to nearest lot lire------------- ---------------------------------------------=-----------•--------=-------------------- - Remo h and/or repairing s ib ' Q - Aj l2 -------------------------------------------------------------------------------•I---------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County d ordinances, State laws, and rule=-.#- -------------------- of the San Joaquin Local Health District. 5i ned (� `-- ----- Owner and or Contracfar( g )= ---------- --- ------------------------------------------------ ( / ) Br-----------------------------------------------------------------------------------------------------------------------------------(rtle)---------------------------------------------------------------- (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 APPLICATION ACCEPTED BY------------ -------- ---- ---- ----------- ------- --------------------------------------- DATE------f—------------------•------------- { REVIEWED BY---------------------------------- DATE- BUILDING PERMIT ISSUED------------ - DATE---�,--------— `Alterations and/or recommendations:____---- _ _ r ----=-------`=-----------------•------------------------------ --------- ---------------------------------------- r ---------- --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------•------------------------------------------------- FINAL INSPECTION BY-------- ------------------------------------------------------- Date-- - r �c ------- 3 - { * 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 ; . Revised W-2100