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Permit No. No. .....-�-�� l APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) pate issued ._ ---. -6_-- `3 1-7(—OPV -_30 Application 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----------------- r- ------�---- -----------------• - -------TO)-------------------L ' r t ---------------- Phone------------------------------------ Owner's Name----------------------- 5 `+ -------- ---------------------------------------------------------------------- Address ------------------------------------------ - - - Phone----------- ----------------------- Contractor's Name---------------------------- Installation will serve: Residence JK Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Number of living units: -------- Number of bedrooms -. ._ Number of..baths ----)-- Lot size ------------4_q ----)4_Q--------------------- Water Supply: Public system A Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ Previous Application Made: Yes Q No D4 New Construction: Yes 0100 No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: 0 (No septic tank or cesspool permitted if public sewer is available within.206 feet.) Tank: Distance from nearest well----- from foundation-----/��------Matg�i��-- _..0 ---------- ----- --------------- Septic XNo. of compartments__.___.... -----------S1Z --•-�-�- Liquid depth Distance to nearest lot line. ... Dis osal Field- Distance from nearest well.-.._ -----Distance from foundation_ ,t 0 T ---------- Number ebor filter material l.. Dep hhofffilter�miaterial_-_..-_- !_--..Total hlength of nC�___._...1- �--_...__---- ' YP r � - . Seepage Pit: Distance to nearest well---------------_-----Distance from foundation.....-..__-_---_.-.Distance to nearest lot line_...___.- ❑ Number of pits----------------------Lining mateiial-- ---------------------Size: Diameter------------..';.- Depth_------------------------------ ------------------Distance from foundation ...____Lining material T------------------------------- Cesspool: Distance from nearest well.-_Diameter--------------------------------------Depth----------------------------------- -- _ �----Liquid'Capacity- -----?------------------gals. ------....._----------------------------------Distance from nearest building___....__.--.- Privy: Distance from nearest well Distanceto nearest lot line-------------------------------------------------------------=---------------'------------------------------------------------------------- 1 Remodeling and/or repairing (describe=--------------------------------------------•-••------------------------•---------- •----------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- -------- -----------------------------------•-•----------------- ------•--------•-------------------- ---------------------------------- _____ _.. _ _ _ . . __ ...................................................................................................................................... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I ies, and rules and regulations of the San Joaquin Local Health District. t ned ---------------------------------------------------- (Owner and/or Contractor) {Si i9 ) --By . _- __ Title --- --------------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be played on reverse side). FOR DEPARTMENT USE ONLY ' DATE_- ---------- APPLICATION i ACCEPTED BY--------------------------- lt�9 -- -------------- 1 - -------------------------------- -- -------------------DATE---A------------------------------------------------------ REVIEWED BY--------------------------------------------------------- . _�. _.�.�.__ BUILDING PERMIT ISSUED------------------•---------------- '_`"..._ ------------------------- DATE.. q • r ----------------------------------------- Alterati s n or recommendations----------- -------------------- -------- ----------------------------- - -- ---------- -- �.— $ ' _ ,� -- - -------- ----- --� 4 ---------_�-::::__-:__:_::_:-:-:___- _- -----• 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 10-52 Revised W-210D