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�s Permit No. _ -7z •- -•- - APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 4 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. 549. // JOB ADDRESS AND LOCATION ------------ r�ritl. ._ v Phone------------------------------------ Owners Name__.._______ - --^------Dry > ------------ Address--------------------------------------------------r-- � ---------- ----�-------- f-------------------------------------------------------------------------------------------- Contractor's Name----------------------•-- -- -r J`T' -< '----------- 1--------------------------------------------- Phone---------------------------------- Installation will serve: Residence;] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑p r Number of living units: _____--- Number of bedrooms --- Number of baths .------- Lot size ______�� '-1--�---/2----------------•- Water Supply: Public system Community system ❑ Private M Depth to Water Table _A;—Jt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy 1Loam ❑ Clay.Loam ❑ Clay ❑ Adobeo Hardpan ❑ Previous Application Made: Yes ❑ NoM 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--------------------Material_____--_---____.__._______________..________--- No. of compartments-------------- -----------Size--------------------------------Liquid depth--------------------------Capacity---------- ------------ Dispo al Field: Distance from nearest well_____$p_�___Distance from foundation_____ IC� -------Distance to nearest lot Numbek01 lines--------------- -- ---------------Length of each line----- 5A51---)_L.Width of trench.-----2`�---- ----------------- Type or filter material------ of filter material------4-----__._____Total length___ Pif: Di _-_______�_�------------------- S=epage, stance-to nearest well--..--.------------- Distance,from.foundation--------------------Distance to nearest lot line__.__________---- ❑ .w Number of pits-----------------+ Lining material----------------------.Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.___.__.________._____.__.__-__ ❑ Size: Diameter-------------------------- -----------Depth------------------------------ --------------------Liquid Capacity--------------------------_-gals. Privy: Distance from nearest well----------------------------------- ------Distance from nearest building---.-- ------.---------------------- _... f ❑ Distance to nearest lot line.---------------- ----------=--------------------•---`---'--•----------------------------------------------------------•------ -------- Remode4ing and/or repairing (desc ibe)---------------------------------------------- -- --------�-------=---•------------------ f :...� ------------------------------------------------------------------ ---------------------------------------------•- -------'------------ ----- - .. v t- ---------------------------------------------------------------------------------------------•--------------------------------------------a---------------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. ''-' .._T -- ------- -------------------------------------------------------------------------------------------------- Owner and/or Contractor (Signed}--____-• - -_-- ( � ) 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 1 APPLICATION ACCEPTED BY-------------------------------------------------- DATE REVIEWED BY----------------------------------------- - DATE- `---- -----------)i�---_------------- ' BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------- ------ DATE-------------------- --•-----------------I----------------I Alterationsand/or recommendations:__'---_------------------•------:---------------------------------------------- -------------------------------------------------- --•-•----------- ---------------------------------------------•--------•---------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ---------------------------•------------------------------------------------------•--------------- FINAL INSPECTION BY:.--------- / = Date-------------- '3 ` �� 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-2100