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r APPLICATION FOR SANITATION PERMIT Permit No. ...._ 3.. (Complete in Duplicate) Date Issued ---- 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. 544. 0,V5– JOB ADDRESS AND, LOCATION_S;_A�__--C4_ _ ___ _________ ------------ -----&�^-�____�-- Owner's Name------ �� -"---- -• ------------------- ---- --------------------------------------- --- ------------------------------------- Address--- -------------- Contractor's Name-------C ------ - - 7R�__I(--tf'3DGr ------------------------------------------------- Phone__'r��_ +7_ __._ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [-] Motel E] Other Number of living units: ___ Number of bedrooms ---2_ Number of baths _i_-__ Lot size ---- _ --- ------------ Water Supply: Public system ❑ Community system ❑ Private ' Depth to Water Table d0_ ft_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes 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 well--/ Distance from foundation---/r __.Materil---��,_!K„/_'' _____________� No. of compartments._.___..�_________ _Size-_Jf�G- "'(a__ ,E_._._Liquid depti,__ '.--__.___-Capacity,_ ____ `°-___ Disposal Field: Distance from nearest weft__,.......Distance from foundation---45-------Distance to nearest lot line_112 Ix Number of lines-------------/------------------Length of each line________ S'�"i!______._.Width of french..._�_"_. __---_--.__-____ - Type of filter material-__ _r__�Q('_-'___Depth of filter material___1.P__-tt -Total length___.____? _'______________________ Seepage Pit: Distance to nearest wefl�___•2r Distance from foundation___. �_�___.Distan e to nearest lot iine___ ��_ Number of p,ts-------4----------Lining mate ria l$i__Gk�C�Size: Diameter-----�jl_�_.__...___Depth...___G _Q_�_-------- - 1 Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material____---____________________.__.-_-, ❑ Size: Diameter------- -----------------------------Depth------------------------------------------- ------- Liquid Capacity----------------------------go. - Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- El _--------____.._____.________-.-_---- --❑ Distance to nearest lot line------------------- -------- ------------------------------------------------------------------------------------------------- -------------•-C� Remodeling and/or repairing (describe)----------------------------------------------------------------------------------------- -----•-- ----------------------------------------------------- r ------------•--------------------------•-----------••--•--------•-----------------------------------•--- --------------------------------------•------------•-•-------••--------------------------------------------------------------------------------------•------------------------------••-------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counti— ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, (Signed)-------•---------------- ------;------------ -------- �wner and/or Contractor) By:------------------t� (Title)- '= ''" --- ------ -------------- - - ----- -(Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY`.:;�-------------------------------------------------- ------------------ --------------------- DATE-�_�---------------- --------------------------------- REVIEWED BY------------------------------�----- DATE BUILDING PERMIT ISSUED-----------�-. ------ --------------- ------------------------------------------------ DATE------------- _O-- Alterations and/or recommendations:---------------------------------------------- ----------------------------------•------------------------------------------••------------•-------------------- -------------------------------------------------------------•--------------------------------------------------------------------------------------- ----------- -----------------•-----------------------•--------------- ---_-_-•----•------•--•----•------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:-------------- ---------- Date---------��+--`-.1 -'--5- ---- ------------------------------ 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 10-52 Revised W-2100