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�� # oel J ' APPLICATION 8911 SANITATION PERMI Permit No. �tlr_ -- ----------- J✓ f (Complete in Duplicate) a,. � Date Issued kipplIclion is hereby made to the San Joaquin Local Health District for a permit to construc),an install the work herein described. This application is made in compliance with County Ordinance No. 549. A a JOB ADDRESS AND LO TION---------- -- ----- -- - Owner's Name j - -- ---------------------------- - ----------------------------- Phone Address---------------------------- - ? ------- Contractor's -Contractor's Name----- ` ..Q-4 --�'" ------ Phone--- €.� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Nur of bedrooms 10%9_ Number of baths ------ Lot size _______ ________________________ Serial No. CAL. License No. CAL. License Renewal No. Capacity Gal.,Weights & Measures No. Previous Application Made: Yes ❑ No IV New Construction: Yes [�rNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if pub' ew is available within 200 feet.) Septic Tank Distance from nearest wel#��i�' istance from foundation_ _ ----------M erial _ f [ � No. of compartments__- _____ ize__�„ _„2�__Liquid depth_L �______._Capacity__ U______ Disposal R Distance from neare well ______________Distance from foundation---I�______Distance to nearest lo`line__�___ ❑ � Number of lines------ -�Q_ ___ Length of each line---YQ__� Width of french____-j-O__ Type of filter materialr__ �'' -Depth of filter material____ _________ ___Total length___ Z>�_________________.___-_ Seepage Pit: Distance to nearest welL_____________________Distance from foundation--------------------Distance to nearest lot line______-____--___- ❑ Number of pits----------------------Lining material----------------_------Size: Diameter-.---------------------Depth--------------------------------- tp Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material-------------------------------------- I6 ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------__._--_______-- ,rA ❑ Distance to nearest lot line------------------------ -- -------------------------- ------- ------------- -- ------------ Remodeling ----------Remodeling and/or repairing (destribe)_-------------- _ -------------------- ------------------------------•-•-•-------------------------------- V -------------------•---------------------------------------------------•------------------------ - -- -- - - -- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 s, and rules and regul tions of fhp San Joaquin Locaj Health District. (Si ned � ------ -- -------------- g } �(9vgrand/o ontractor) BY• - ------------------ -----------------------------------------------------------{Title)-- ------------------ ti (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 APPLICATION ACCEPTED BY------------------ ----------------------------------------------------------------- DATE- REVIEWED ATE t1_ REVIEWED BY_ ------------- DATE_.------------------------------------------ BUILDING TBUILDING PERMIT ISSUED--------------------------- -------------------..--------------------------------------- DATE Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- ---•------------------------I------------------------------------------------------------------------------ --------------------------------------------------- -- ------------------------------------ FINAL INSPECTION BY:------ ------------------------------------------------------------------------- Date---t 7. - ''r 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---4-2M 9-51 Revised W-2100 �y'��