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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in u licate} - Da#e Issued _A=-�• ,.I �+�_ r Applica+ion is hereby made to the San Joaquin LocI H�strict for -permit to construct and install the wor herein described. This application is made in compliance with County Ordinance M. 549.E , JOB ADDRESS AND LOCATI N__. -- dvti _ _-°� .t vc. $ - Owner's Name. _ ------------ Phone____. Address----------- 1---- r� Contractor's Name----- - -------- -------••-•---------------------------------------------- -----------•--------•---------------- Phone--------- - , Installation will serve: Residence Apartment Mouse ❑ Commercial ❑ Trailer Court ❑ Motel F1 Other ❑ Number of living units: Number of bedrooms ___ _._ Number of baths --� -_ Lot size Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table ._ aft. Character of soil to a depth of 3 feet. Sand ❑ Gravel Sand Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No n New Construc�es 4 No ❑ - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted'if public sewer is available within 200 feet.) C� 1 / t Septic Tank: Distance from nearest well --.Q _10-__Distan e fr m foun ation----10----------Ma ria) _ ---------------- ---- r� No. of compartments------, +-------- ----- - .---Liquid depth--------�'-------------Capacity..��Q---------- Disposal Field: Distance from nearest well---4_Q_.._Distance from foundation----1_9-----_ -.Distance to nearest lot ] Number of lines__--._--3------------------- -- Length of each line _�P-�--_ --_ ." , 1/idth of french----3_Qr�---------------- Type of -Filter material___ Depth of filter material____. -_g-----------Total length___/_Q_Q__________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__--_-.--________ i ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth_-____.__________________------ Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material _-_;_._.____________________-____-- { ❑ Size: Diameter----------- ---------------Depfh------::---------------------- ------ Liquid Capacity gals. ----- ------ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------- F1 -------,---------------- •-------------.❑ Distance to nearest lot line------------------------------ r� r3�Cj�� Remodeling and/or repairing (describe): --------- ---------------------- - =----------------------I•-•------- -----------------------------------------------------------------•----------------------------------------------------------------------•------------------------------------------------- _--------------------------- ----------------- -----------------------------------------------------------•----------•--------------------------------- ----------------- ---------------------------------------=------------------- ------ 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, and rules and regulations of the San Joaquin Local Health District. (Signed)..--"- �, ' '� -- � U --- ------"---------------------------------------{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 i APPLICATION ACCEPTED BY--------------------------------------- -1------- -- - ----------- -------------------------- DA TE BY--------------------------------------------- ----------- -- --- - --- - - - - ------------------------._ DATE --� .:3 BUILDING PERMIT ISSUED------------------------------------------ --- DATE______- _ _ F --------------------------------------------- Alterations and/or recommendations----------------------------------------------------------•---••--'---------------------------••---------------------------- ---------------------- -----------------•. --------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------•---------------------------•------------------- -•---------------------------------------------•---------------------------------------------------- ------- -------------------------------------------------------------- ---------------------------------------• f ------------------------- ------------------------------------------ ---- ---- --------------------------------------------- - - ------------------------ -------------- ------ E FINAL INSPECTION BY:.--------- �f --- ------- ------ 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