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APPLICATION FOR SANITATION PERMIT Permit No. -• - .!... .-,[Complete in Duplicate] IData Issued I _ 4_ j A plication 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. r .JOB ADDRESS AND LOCATION- ------- t __ --------r----•----------------- --------------------- -------- C 'Cf� - `L� ` --------- Phone------------------------------------ Owners Name ----------- AddreAddress ss--------_---------------_--------------------- --------------------------------- L j Contractor's Name { � c ------------- Phone. .r l Installation will serve: Residence ❑ Apartment House ❑ Commercial�Trailer Gourt ❑ Motel ❑ Othe Number of living units:____ Number of bedrooms -------- Number of baths _4_ Lot siC?_0. `?-"_"----- -- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet:, Sand [I Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ❑ No�New Construction: Ye'xNo ❑ �•• TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public `sewer is!available within 200 feet.) Se tic Tank: Distance-from nearest well_____-QI `9.Distance ffom founcPation__.G0-----___.Material---- No. of compartments_---- � / __._..__Size___,- Liquid depth__._.�-----_________..Capacity---6,l�A- Dis osaI Field: Distance from nearest ell-_ -6-U_9—Distance from foundation____ -. -----Distance to nearest lot linep___6----- Number of lines----------:-�---------------- ----Length of each line-------t_d0t-----------.Width of trench-------.- ---------- rr. r Type of filter material---$;�- ,_Depth of filter material-__ __? ___.___-Total length__--.--____�_ ____________________ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----------------- �0 ❑ Number of pits -material-- Size: Diameter Depth-------------------------- I - Cesspool: Distance from nearest well-____________.-.Distance from foundation------------------- Lining material--------------------____:'.._.___---_ ❑ - Size: Diameter- --------------- --------Depth---------------------------------------------------Liquid Capacity-------------------- -------gals. Privy: Distance from nearest well----_--------------_-----------------_-----------Distance from nearesr building_.---------------------------------------- ❑ Distance to nearest lot line--------------------------------'--------------- -------•---------••----- --------------------------------- ----------------------------------- � � F Remodeling and/or repairing (describe):------------------------- ---------•----------------------•----------------------------•-------------•----------------------------- -------------------------------------- ------- -------------------- ------------------------------------- ----------------------•----------------------....---------------------------•--------------------------------••-•----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin-County ordinances, Stet ws, and rules an reg la •ons of the San Joaquin Local Health District. 9 ed) _ ------------=--------------------------------------------------------------- By ------- ------------------------(Owner and/or Contract - d o or Title s (Plof plan, showing six of lot, to tion of system in r tion to wells, 6uildings, etc., can be placed on reverse side]. FOR DEPARTMENT.USE ONLY APPLICATION ACCEPTED BY------------------- --------C17&0 --------- -----'= ---------------------------------------- DATE-------- - ... .. . -'s ----- -------------. REVIEWEDBY----- ----------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------ --------- BUILDINGPERMIT ISSUED-------------------------------------------------- ------------•---•-----------------•----------- DATE------------------------------------------------------------- Iter tions and r recom endaf ons•__._--_-t -------------- -•--- ..............c___ - 41 - � g ,rl - -------------- t/f/E !•� -- Date.--- ._�7 ----------------- SAN - ` FINAL INSPECTION BY:____________________-__.--._____ f 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 7 ES-9-2M 10-92 revised W-2100 "' - '