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a APPLICATION 4 �� �'� FOR SANITATION PERMIT Permit Na. . ..... ................ (Complete in Duplicate) f Date Issued Applical-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 AN OCATlON.. &I'P•tl ---'Q'----, - .0-0,� '`G � lK-_ .: Owner's 'Name. 777777 ___ 2 A-)�-' -�---------•-------- ---- -;.�:.�_:--- �� ----- Phone------------•---- Address-------------- t -------- - •------- --- j---------------------- _ ................................. Contractor's Name Phone ' Installation will serve: .Residence [ Apart , nt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: ___-r _ Number of bedrooms __ ' - Number of baths ---- ;otsize .Q-0-X- _, f -------------------•--- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -eft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoV New Construction: Yes J 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 wail_-_�___--- Distant from foundation---_- -1-Q- ---.Materia--------- i No. of compartments------------------------ Size----- __--vK-- ,S- �"Ciquid depth------------- --- ---------Capacity--- -------------- Disposal 4 r— Disposal Field: Distance from nearest well:_.�j_(.-_.Distance from foundation----- _+----Distance to nearest of line------ Q• Number of lines---------------1_----------------Length of each line--- �,.- Width of trench------ f--/1--__----_ CN Type of filter material___,5_T -eDepth of filter material-----/ -------Total length-------,r✓-o`'�_-_U------------- -------- eopage Pit: Distance to nearest well----------------------Distance from foundation---___..--- .--.Distance to nearest lot line----..--__--_--_- ❑+ Number of pits----------------------LiniTng material___a.-_-..__-----.,v--.Size='Diameter------------- ----Depth--------------------------------- Cesspool: i Distance from nearest wefi----_----::__-_Distance from foundation _ �----.Lining material_-.--__--_-_----__- ❑ Size:.Diameter--------- ------- ��--- -De th.- :: — Liquid.,Capacity_ - a -------------- - -,-�, ....- � _ row...-: .� . ,��_-`:..„9 Privy: Distance from nearest weft ---- - ------- -- - Distance from nearest building g------------------------------------------ El- Distance to nearest lot line--- ------------ ------------------------------ �'— ---------- Remodeling and/or repairing (describe)-- ------------------------- '� -----� :- •----_------ t I --- ______------_____-------------_______________________ v__- _.____----�.-___-.-_____-_--_------•---_-___--___-------_--_.---_---_-__.--____------_--_--- I hereby-certify-fhat I have prepared Ais-applidati' afid'thaf the work will'be done in accordance with San Joaquin County, ordinances, Sate laws, and rules and regulations of the San Joaquin Local Health District. (Signed ---- -------------------------- ---------- ----------------- ----- -_I Owner and/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). FOR DEPARTMENT USE ONLY t APPLICATIONACCEPTED BY-------------------------------------- ----------------------------------------------•----------- DATE-- REVIEWED BY--------- --------------- ----- ------ ---- --- ------------------------• DATE - - - BUILDING PERMIT ISSUED -----------=------------------- Alterations and/or recommendations___________ -- -------------------- DATE. >" � � - - - � -----------•--------------------------------I- -------•-----------•------------------ ! -----------'------- -- -----•--=-.--: --------------------------------------- '--------------------•-------------•-- - ------------- -------------- ------------------- FINAL INSPECTION BY----------------------------- -- -- --- ---- -'�'"-- ' 9 Date------- - --------��-�--- ------------•----------•------•------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" S+reet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100