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fl �( APPLICATION FOR SANITATION PERMIT Permit No_ ______ ________________ (Complete in Duplicate) _ Date Issue Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. c This application is made in compliance with County Ordinan e No. 549.------ ----/ / � 3 �vU- ��-( -----•-----•`---------- - - -----------------•------- JOB ADDRESS AND LOCATION____. ___ __ . ` ` /`��0-7 Owner's Name---------------�f'�'M--- -------N�-fl/�175l ------ - Phon T- ----•e2 Address-------------------------------------------------- !1 k �/ --- --------------------------------------------------------------------- Contractor's Name K1'f_�, C Phon 87-4 ----- `�� ------- Installation will serve: Residence 0---Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Insta I �p ❑ s i Number of living units: " " Number of bedrooms bar ofebaths oTable ,� � � ' Water'Supply: Public system ❑ Community y El Private pthto Water Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes 9;,�o ❑ 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-Y00- -Distance from foundation----40_._-.___.Material______________.-_-_ _---.._____________._- No, of compartments__�----._____________Size��F�---------- ,--Liquid_Liquid depth__ ��..____-___FCapacity�/0 ---------- Tor r r Disposal Fieid: Distance from nearest well-OC.--l-Distance from foundation"_ :__..Distance to nearest lot line______* -- [ Number of lines-----j---------------------------Length of each line--- , ---__------------.Width of trench__,Z_�jt<___.________-____--- ♦-------- - ,y ---------------------------- Type / Type of filter material-__j�yw-_�____Depth of filter matena!____l_. __ Total length______./.- ______ ___________r! Seepage t: "'Distance to neares well-7-_D-Q_-"~_J-Distanc •fr f undation_:_�.�____-..Distance to nearest lot line-----1_sl_____ Number of pits---- _-- ----"-----Lining material! __�n____ �.--.Size: Diameter------c, - -��--..Dep th_at ----------------- Cesspool: Distance from nearest well______-----------Distance from foundation------------------- Lining material-------------------------------------- ®v Size: Diameter---------------------------------------Depth----------------------------- -------------------(--Liquid Capacity----------------------------gals. N Privy: Distance from nearest well-______________-------------------_--------------Distance from nearest building__:__._______.______________------.____._. ❑ Distance to-nearest lot line- = ------------------------------------------------------------ ------------------------ =--------- Remodelingand/or repairing (describe)--------------------------------------------._._..-_------------------------------------------------- ......---•-------------------------------•-_-- -------•------•-"-------------------- --------------------------------------------------------"----------•-----•----------------=----------"---------=-----------------------•--•---------------------------------------- i -------------------------- ----------------------- --------------- ----------------------.....--------- --------------------------- •------------------------------------------------------------•-••---------------- I herebyertify at I have prepare this application and that the work will be done irr accordance with San Joaquin County ordinances, St to laws, and rul s and re ations of the San Joaquin Local Health District. (Signed)-----• ---- --------- -- --- ------ ---- ----• - ------------------------------------- Contractor) BY: = -•------------------ --- { - ------------- (Title) (Plot plan, showing size of lot, location of system in re on to wells, buildi s, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -------- ----- --=------------------------------------------------------------------------ DATE- -ten -----------•---------------------------- REVIEWEDBY------------------------------- -----r------------------------------------------ -------------------------------------- DATE--- r'z-------------------------------------------------- BUILDINGPERMIT ISSUED--------------- --------------------------------------------------------------------------------------- DATE------ ---------------------------------------------- Alterationsand/or recommendations:------------------------------------- --------------------------------•-----------------------•-""--------------•----•-•--...................... ----- -----•-•--------------------------------------------------------- ----------------------•----------------------------•-----------------------------------_•- ----•-------------------•----------- -------------------------- -•----------"----"------------------ •------"------------•--•---.--------------•------------------------------------------------. r . �r 06 FINAL INSPECTION BY:..-. --"=----------=--- Date--- _.. - ---- ------------------- 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 FS-9-2m Revised W-2100