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APPLICATION FOR SANITATION PERMIT Permit No. ------------- in Duplicate) Date Issued 1.2`_�-- pp k5' Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he4-� de cubed. 7This application is•made-in compliance-with County Ordinance No. 544. ' ;.E C�,yP,t} JOB ADDRESS AND LO TION..._ _. ' ' �'� g ca'`' Q---- �--51-9`-_ ------ n l s Owner's Name J = - --- ---------------------- ---- - Phone-lYr-r -- �. 3 _ _ Address--------------------- —f ^ - ----------- ------------------------------------------------------------ --------------------•'--- .------------------------------------- - Contractor's Name------------Q___ ------- ---- ------------- 3 Phone - 6 '7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑- Other ❑ 22 ��! � Number of living-units: __.�___ Number of bedrooms Number aths -_�___ Lot size __________..________________________________________________ ti Water Supply: Public system-❑ Community system ❑ Private Depth to Water Table ________ ft: s Character of soil to a depth of 3 "feet Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ElNo ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: E (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well' 26__'x____Distance from foundation___147--- Material_____ -- ____ _.__ __-.. __-_____ ---- No. of compartments__.Z------------------ __Liquid depth____.97_S_'_----------Capacity- from sd_______ om osal ie"��umaber earest weft:___._-.------_._Distance th of reach line ation------------- -----Widthcofttre chest lot line----- -------- of i nes - Type os filter material-------------------------Depth of filter material--------•-.------------Total length----------------------------------------.- - - Seepage Pit: Distance to nearest well__--------------------Distance from foundation......:.............Distance to nearest lot line_________________ ❑ Number of pits----------------- ----Lining material--------------------4___--Size: Diameter------------------------Depth--------------------------------- ________________ _ Cesspool: nearest well , _ize: Diameter _Distance from foundation material________.______.____.____ .__-_.____.. - -Dent h_---------------------------------------------_-Tiquid. Capacity- --:_-- Privy: Distance from nearest well __.'__________________________----________------Distance from nearest building__________.__._______________________----- ❑ Distance to nearest lot line----------------------------------------------------------------------------- --------------------------------------------------------------------- Remodeling and/or repairing (describe)------ ----------- - --------- -----------------••------ --------...-------------------------••---•-------- I ---------------------•----•-------•------------•-------•-•-----------------•---.-----• ------•----------------------------------..._.......-_.------- ----------------------------------•-----------•---•- ------- i ------------------------------ ---------------------—--- : - - ------ --- ----- --------------------------------------------------------------------- -------------------------------------------- --------- ------- I hereb ertifythat I haveprepared this application and-that the work will be done in accordance with San Joaquin - Coun ordinanc S, State-1 ws, and rules an gulations of the San Joaquin Local Health District. (Signed)----- —_. -- --------- ------------- `---------------------- -- --------- --�0!� Contracfor] I Piot Ian showing size of L� ITitle�,aced`on �itrt. - BY= . ( p g lot, location of system in rel,pion to wells, buildings, c., can be reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED'BYZ--- -------------------------`--------------------------- ------------------ DATI,,,. ----------•----------------•----------------------- REVIEWEDBY--------- ------------'-------�- -----------------------F------------------------------------------------------ DATE � ------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE--------- ----------------------------------------------- Alterations ----- - Alterations and/or recomm e"ndations-------------------------------- ---------------------------------•----------- ---•-•------------------------------------- ------- -----------------------------------•--------•---------------------------------------------------------------•-_---•---- -------------------------------------------------------------------------- -- --•._..------- -------•------•----•----------------------•--------•-•-••------•-•----------•--------------------- ------------------.-...... ----------=-----------•----------•-- -----------------------------=--------- ----------------------------------------------------------------------------------------------------------------------------------------------- ry -------------------------------------------------------- ------------•--------- ------------------•----- --------•----------------------------I=--------=------------------------------------------------------------------- y r FINAL INSPECTION BY::= = = ------• - Date-----/------- 1____- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 306 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100