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APPLICATION FOR SANITATION PERMIT Permit Na. -7-•�� (Complete in Duplicate) i Date IssuedS Application is hereby made to the San Joaquin Local Health District for a permit to con tr-uc+ an install the work herein described. This application is made in compliance with Count Ordinance . 549. > -1 e R JOB ADDRESS TI c;------- ---��-- - - - ---•----- - --- �------ - ------- -- ----------•---- -- -------� ------- Owner's Name----------------------- ---- , !_��_�� Phone----- Address-------------------------------- - ---------------- ------`-"------ -------- ------------------------------------------------------------- - ---------------•--- Contractor's Name --------- -----•._------------------------------ - t ------ - Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Otherii Number of living units: -_ _ Number of bedrooms ---=Number of baths Lot size --- ___ g_&674---------------------------- Wafer _-_---- ---------- ----Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 fee+: Sand E] Gravel ❑ Sandy Loam E] Clay Loam [:] Clay ❑ AclobeN Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ NOX 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------------------._____..____---_-____-_-___--. Q ❑' No. of compartments--------------------------Size------------------------- ------Liquid depth--------------------------Capacity- ------------ - r f Disposal Field: Distance from nearest we€iN21P/E.._.Distance from foundation,2-00........Distance to nearest lot line...__. Number of lines-----1 R ---------Length of each line-_-- - __`---.��---.-.Width of trench-._7-K-1.11 _��C------------------ � Type of filter material_!�'1_Ro_CX----Depth of filter material------- --____---Total length---------f--- K- 11------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation----_-_--_-__--_-_.Distance to nearest lot lint ----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth.------------ ------------------ i Cesspool: Distance from nearest well----------------Distance from foundation_-_.--_-___--_-_-.-.Lining mater'sal__.___-.._--_.--_I_- ----------------- Size: Diameter----------------------- ------Depth------------------------------------ ------------------------ -- -------- -----_Liquid Capacity-- IlACounfy - als. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.--_____-___-______ ..._-.-.-. ❑ Distance to nearest lot line----------------------------------------------------------------•-------------- ------------------------------------- --------- Remodeling and/or repairing (describe :--- -- -_'-- 1-- ----------- ----•--- " .---.---- 1 ------- - ---------------------------- -------•--------• ----------------------------------------------------- ---•-•----------•------------------------------ - ---------- -------- -1/-----••----------- ---•-------------------------------------------------------------••-----•.----------- --------- 1 hereby certify that I h pared t i application and that the work will be done in accordance with San Joounty • ordinances, State laws,(ara r les a regula ion f the San Joaquin Local Health District. (Signed) t ____(Owne and' orContractor) BY=-----------------------------C.�-� ------�-------- - ---------- --- ---- ----------)Ti+le) L Plot plan, showing size of lot location of system in relation to wds, buildings, etc., can be laded on reverse side). # y Y s # ) FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY------------- ---- -- •- ----------------- ----- --- --•------------------- DATE----------- �I REVIEWED BY-------------------------------------------------------------- DATE------------ ` �j -------------------------•------------ BUILDING PERMIT ISSUED--------------------------------------- DATE. Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------- -------------- ��.._... JI 11 �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 I Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 10-52 Revised W-2100 - I r