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y APPLICATION FOR SANITATION PERMIT Permit No. _. __. _ (Complete in Duplicate) Date Issued ___ ----7147-1 Thi slappl cation is madeanecompl ante w fhto the San gCountyuin a0 diinat ceDlNo. 549r a permit to construct and install the work herein described. f JOB ADDRESS AND LOCATION. ,�Z44-1-- _ L�-_+Q,�_?rQ-4-e-e',_ 2-_ -- Owner's Name__--Gr ---- -----•-•_--___--___ i 6-- 1--t - ----- _--- -- -------- --- - f ,-------------------------------------------------------------- -- � Contractor's Narne----------------- �5 - . Phone ---------- Installation will serve: Residence A rtment House ❑ Commercial ❑ Trailer Court❑ Motel ❑ Other ❑ Number of living units: _1______ Number of bedrooms ___I -_ Number of baths 1----- Lot size,_____________________________ Water Supply: Public system ❑ , Community system;[] Private ® Depth to Water Table'l,7--off. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ] Hardpan_W Previous Application Made: Yes ❑ No V New Construction: Yesx No ❑ k N► TYPE OF INSTALLATION AND SPECIFICATIONS: ! (No septic tank or cesspool permitted if public sewer is available within 200 feet. 3 ___ Septic Tank: Distance from nearesi well__�D�Distance from foundation_ Materia /►e No, of compartments Y P Size-------T-00-G{-d- -- Liquid depth_' CapacitY --------------- --- = qq � Dis sal Field: Distance from nearest weil__ �-___.Distance from foundation----1_a____......Dis nce to nearest lot line.... Number of lines------------ ---- -_----- Length of each line_-----------7-5-_.�-----.Width of trench. a" "-r�-______- - Type of filter material_ __ _-De th of filter material_______.ZF_ P Total length -7�--------------------� 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______________-____.__-_____ t ' ------ ❑ Size: Diameter--------------------------------------Depth------------_- _...._---- Liquid Capacity gals. Privy: Disfance from nearest well____________________________________.________._Distance from nearest building` ❑ Distance to nearest lot line Remodeling and/or repairing (describe):. - 1 -- -�- _ - r-----}T-- -------- ------------ --•---- -- ------- ------ - (/// --------------------------- �%± ��R- --- ---------------------------------------- ----------------------------I----------- --- - --- --------- --------------------------------------I----------------------------------------------------------------------------V----------------- - ------ -- -- - - - - ------------- --- ----- ------ - --- ------ -- - - -- - I hereby certify that I have prepared this application and that the work will 6e done in accordance wi+h San Joaquin County ordinances, State laws, and rules and regulations of.the San Joaquin Local Health District. (Signed)------------------------•----------••------------------------------------------------------------ {Owner and/or Contractor) -------------------------------- ------ . By:---------------------------------------------------- --------------------------------------- ----------------------- --------------Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------ DATE-------- +- REVIEWED BY _ ------ DATE BUILDING PERMIT ISSUED ------------------•------ ------ DATE Alterations and/or recommendations--------------- ------------ ------------------------------------------ ----------- r- -----•-•-----------•--------- ----""yam a G�'�_�� ---- -----I------ - ------- ------------------- ---------- ----•-----------•--------- -------------- ---------------- ---- --------------------- --- --------- ----- ---- ------------- i FINAL INSPECTION BY--------- ------- -- ---------------- --------------------- Date....... _�_. ------------------------------------------------------------ k r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manfeea, California Tracy, California 1 ES-9-21M 10-52 Revised W-2100 1