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f APPLICATION FOR SANITATION PERMIT Permit No. ....tg"G7 u (Complete in Duplicate) - 4_. _ y ., Date Issued -- Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install fhe'work heein described. This application is made in compliance with County Ordinance No. 549. a JOB ADDRESS AND LOCATION_.__,,_.. 4_--3a R , ------------------------------- ------------ ----- - - - Owner's Name__ -, • .1- ' ----------------------- --------- ---- - Phone41= 15 �� Address_ - --- ------ - 1.417 Contractor's Name----------- ------- ` Installation will serve: Residence Apartment House ❑ Commercial Trailer Court f[ ❑ ❑ Motel ❑ Other ❑ , Number of living units: __Number of�bedrooms�-Number of baths ./- Lot ze .____ .`� /ate' --------------------------- Water Supply: PUblic'system Community system ❑ Private ❑ 'Depth to Wafer Table S ft. Character of-,soil to a deptho' f 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayAdobe r i ❑ Hardpan ❑ Previous Application Made: Yes ❑ N oX I New Construction: Yes ❑ Nom i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank`or cesspool permitted if public sewer is available within 200 feet.) I Sep c T nk: Distance from nearest well-__ w____- Distance ifrom-foundation-----------------`_-.Material--------------------__________.- -------------- No. of compartments -•--Size----_--------••-------••-------Liquid depth-------------------------'Capacity D' osal Fie Distance from nearest well-__.-_.--------__.Distance from foundation----------------- to nearest lot line•_______ Number:of.lines -- --------------------Length of each Y line-------------------------------Width of trench- ------•-------------------- - Type of filter material-------------------------_Depth of filter material = _____•._�--_..__Total length__.-___-_____---.--------------- 5ee if: D1isfd� eer oto"n}are t well_- __� Distance" "foundation___ ______________. p g ----------- .f� � Distance to nearest lot line__��----_ 3 Cesspool: Distance from nearest well------.-----------Distanlce-- -��--Size: Diamete'r_..__-�__-_. t , i � t E from foundation--------------____.Lining material -__.___-_----_-__--_ (�� ' ❑ Size: Diameter_________ ___________ " t I "111 .,.......---Depth-.' ------:`-------------------- ---------Liquid Capacity---------------------------gals. Priv Distance from nearest well-__.-_----__.___ -,_-_"r =' --________=Distance from nearest building l Y� - —Distance❑ nearest lot line- ------="=----------------------------- - —--` ,.s : Remodeling and/or repairing (describe):_____________________.____ ______--- ..........._:_ .., , - ,..._ ,,.. r_ -------------------- -----------------------------------------I------------- --------------I---------------------- ---------------------- --------ZZ--------------- ------------- - --- --------- ------ ----------------------------------------• -------•---------------------•-------=•-----------------•---- --- t I hereby certify that I have prepared +his applica+ion and tha+ the work will be done in accordance with San Joaquin County- ordinances, ounty-ordinances, State la d rules and regulations of the San Joaquin Local Health District. (Signed)------------------------ '-q'i kt--1- 4`'---------r caner / Contractor) --------------{O _ � and/or 0 BY: ` ��' 7 - (Title)---�� r ---------------------------------------- (Plot plan, showing size of lot, location of system in cele+ion to wells, buildings, etc., can be placed on reverse side). s r FOR DEPARTMENT USE ONLY APPLICATION --------- ----- ---- ------x=-•------------------------------------------------- DATE,----�------------------------------------ ------------ REVIEWED ---------- By Y_ ACCEPTED 6Y--- - DATE BUILDING PERMIT ISSUED DATE----------- --- Alterations and/or mrnen ations______________ _ - ------------ ----- ---- ---------- -------- �"�,-------- � _. . ____________________-- - ---• � ------ -------------------- -s - - - ------ --------------------------- --- -- -- - ----- - 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 ES-9--2M Revised W-2100