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APPLICATION FOR SANITATION PERMIT Permit No. .. ` ' - - (Complete in Duplicate) Date Issued �3 *� 062 06,C-Sq - - Wication is hereby made to the San Joaquin Local Health Distri t for a p rmit to construct and install the work her in described. This application is made.in compliance with County Or finance N . 549. JOB ADDRESS AND O ATIO ----- -------------- ••-- ---------------;i---------------------------------- • ------------ Owner's. .�_ Name- -- ----- - --- --•-� ------------------ --------------- - ------------- -------------------- Phone_- ----------•Address-----------_-- I1 ---------&---- -•- - --- -- -- --- ----- -----------------------------•------------------------------------------------------------------ •------- Contractor's Name —= Phone-- Installation will serve: Residence ❑~ Apart House ❑ Commercial ❑' Trailer Court ❑ Motel ❑ gther ❑c,,_' r Number of living units-. Q Number of bedrooms -0 Number of baths _4* -Lot size ----�- ____ -------------- Water Supply: Public system [I Community system ❑ Private, Depth to Water TableoZ- ft. Character of soil to a depth of 3 feet: Sand Gravel El Sandy Loam E] Clay Loam ❑ Clay E] Adobe E] Hardpan E]Previous Application Made: Yes 0 IN New Construction: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFIC TIONS: . r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well-________________Distance from foundation--------------------Material---------------------------------------- -------- t ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------- --------:-Capacity--------------------- I Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line------------- El of lines-----------------------------------Length of each line-----------------------------.Width of trench------------------------------�` " [ Type of filter material_________________ Depth of filter material-----------------------Total length----.___.__________-___--________._____._ E �vt Distance to nearest lot line- Seepage Pit: Distance to nearest well.._._ .__-______Distance"M110 dation____ ____________.Number of pits------/ ------------Lining materia .Size: Diameter. .Depth Cesspool: Distance from nearest well----------------- from foundation___________________ Lining material___.._____._-__----._------- Size: Diameter- Depth----:: _ Liquid Capacity-.------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildingzr-------------------------------- Distance _ ---______-----__-_____._.__.Distance to nearest lot sire____ -------------------------------- -------------------------------------------------------------------- ----------- Remodeling and/or repairing (describe)---------------- / ------------------------------------------------------------ '------------------------------------------ •: - --------------------------•---------------------------------`------------------------------------- i ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have repared this a plication and that the work will be done in accordance with San Joaquin County?T ordinances, Stat s, an ul and regulati ns f the San Joaquin Local Health District. A 1 (Signed) = --- - -=�`-p'`-�%--------------------------------- ---------- ------------------- - --(Owner and ar Contractor) By:--------_-------- --------- a -- {Title) ' ' r ------------ (Plot plan, showing size of , location of system in relation to wells, buildings, etc., can be ed on reverse si i FOR DEPARTMENT USE ONLY kAPPLICATION ACCEPTED BY----•- - ----- ------------------------------------------------------ ----------------- ---------------- REVIEWED BY--------------------------------------------- ------------------------------------------------------------------------------- rDATE----------------- ------ ------------- A---------------------------.,i- -------._.-.R---------------------------..r_ DATE ---- ----- ... . B11LDING PERMIT ISSUED nAlterations an or recommendatio - ----------- ---------------•-------------------------- --------------------- ------------- I----- --------------------------- ------------------------------- ----------------------------------------------------- ---------------- --------------- ----------------•- ---------------------- ------ ---- ---------•---------- ----------------------------------------= -------- - -------------------------------- .. __-- - ✓ FINAL INSPECTION -- --------•-------- ----------------------------- - Date- --- --- ------------------- -------�-----------�---- SAN JOAQUIN LOCAL HEALTH D T 130 South American Street 300 West Oak Streat 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California q. ES-9-2M I0-52 Revised W-2100