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APPLICATION FOR SANITATION PERMIT Permit No. 1�.. 7...._... (Complete in Duplicate) Date Issued ------------- Applica}ion is hereby made to the San Joaquin Local Health District for aepermit to construct and install,the work herein described. This application is made in compliance with with County Ordinance No. 549. ' f'r�" ,. m� . . " ;;! �;. JOB ADDRESS A LOCATION s • O D ESS Nle LOC O ff.. r�------------------------- -------------------------- Owner's Nam __ ------------------> r��-- �--' � ��'�� --- � Phone Address � `_ _''7, Contractor's Name-- �.�''- - ------ ---- Phone--------------------------------- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Mot I E] Other / Number of living units: __'____ Number of bedrooms --- �� ~.-_. Number aths -__I___ Lot size ---e!67X r---- -. __ ___________________ Water Supply: Public system E] Community system ❑ Private Depth to�Wafer Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam r Ciay Loam E] Clay F] Adobe/Hardpan E]Previous Application Made: Yes ❑ No Ed New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu^blit sewer is available within 204 feet.) Septic ark: Distance from nearest welfL+ '�Distances from f�junda 'o ------- Material _R No. of compartments______________ _______ Size__- -- .'_ . Liquid depth_-________�? '-.______._Capacity___ __. _____- Dispo I Field: Distance from nearest welf�92-____""�Distance from foundation-- -- istance to nearest lot line---- P Number of lin s-_-___(_____ _____�,C---______ ..Length of each line_l� Width of french_-___±�t_'�r-_=_'_�_____________ i�e C f l }• r Type of filter'mater :_______ pth of filter mater al--------/__ _______Total length----------- _ � __________________ t - Seepage Pit: Distance to nearest well___-------------------Distance from foundation-------------------- to nearest lot line-____-__________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------------------•-------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 11'❑ Size: Diameter--:----- ------Depth--------------------- ------------ ----------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-----------------------------------_-----------__Distance from nearest building_____-_______________---..___---.____--__. ❑ Distance to nearest lot line-- ------------------------------------------------------------------------------------------------------•------ Remodeling and/or repairing (descrihe)=------------------------------------------------------------------------------------------------- ----....---•-----------------------•-------------------- ------------------------------------------------------------------------------------------------------------------------------------•-------.----------------------------------------.----------------------------------- ------------------------------------ ----- •--------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------- 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 r s and regulations of the San Joaquin Local Health District. ----- (Signed)----------- ------ {Owner and/or Contractor) IF 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 APPLICATION ACCEPTED B M ----------- --- ------- -- ------- ---•-----•------------------------------ DATE""' , .� REVIEWEDBY------------------ -- --- — ----------------------------------------------------- •------ DATE---DATE--tC-------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------------- -------------------------------- DATE-------tN--------------- - co n ---- --------- .1 - ' ^-- - ---•----------• - teratigns and/or, ecom, en ations' = - --- . .�.--••: fes.:--i-`T--� -=A- --- :. ------------_---- ---- ---._.f.! -------- r - ----' --------------------------------------•----•--------------- y Sv="�_ 'V "-^.'T _..a .`�J`•AV'r'-^ � Vf{�[eG+T 1 -3- ./ F ______________________________________________________ __________________ _________ �t - �I 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 ; Revised W-2100