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APPLICATION FOR SANITATION PERMIT _T Pertnit No. ._ . ___ r _a (Complete in Duplicate) 111 ielv Date Issue ___/ -:' ._: 3 Application is hereby made to the San Joaquin Local Heal t 'strict for a permit to construct and install the work herein described. This application is made in compliance with County Ordin ce o. 549. JOB ADDRESS AND LOCATION-------------- __. I� ------ Owner's Name--------------------------------------------- -- -------- - ---- ----I--- ------ 146) JlC_'_r-�------------. .. Phone---�,�d-Q- Address. 1� ----------P ---- --- - ........................-•-------------------------------------- Contractor's Name-------------------------------------- --F�I�- ------------ ------------------•---------------------------------- Phone---- it Installation will serve: Residence ® Apartment House D Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I___ Number of bedrooms . _ Number of baths __1___ Lot size __-_- '1J r ------------------------------------- Water Supply: Public system ;4, Community system ❑ . Private ❑ Depth to Water Table Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [ Hardpan ❑ Previous Application Made: Yes ❑ No r' New Construction: Yes 5( No ❑ 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_ "_�- _sS_--Liquid depth__.S?-' O ---------Capacity-X P.Ae.---\ jl: ( 3.f o�+��t' fUisP _ I osa 'e � rnearest wellxr � .Dstance from foundation__Y--,X.. -__.Distance to nearest lot line______ _- Numbeor lines - Leingth of each line_1G�______--------------Width.of trench._�."°�."__�_=-4------.- Type or filter material_______ _-- 1Depfh of filter material----1AP..........Total length___-,a--- !'- ---- Seepage Pit: Distance to nearest well_._ e---_-Distance from foundation____..'..___:Distance to nearest lot Number of pits---4-----------------Lining matlerial_e-4° ----.Size: Diameter_-Z--3-`---------Depth---A- `------------------- Cesspool: Distance from nearest well------------------Distance from foundation__._.___t.___:-.Lining material------------------------------------- El Size: Diameter--------------------------------------Depth---------------------------------- ---- -------Liquid Capacity---------------------- gals.' Privy: Distance from nearest well----------------_____I�- -------------------Distance from nearest building_----..___________________------ --_--- ❑ Distance to nearest lot line--------------------IIS -------------- Remodeling and/or repairing (describe)------------ -----------------___�I -------------------------------------------------------------- -----•-- ----------- --------------------------•----------------------------•------•-----•------ -----•-------------------------••-------------------•-------------------------------•---- I I hereb ce 'fy that I have prepared this application end that the work will be done in accordance with San Joaquin County ordinances tate ws, and es and regulations of the San Joaquin Local Health District, (Signed)------ - ----=_ --------- --- -- -- ----------- _ Contractor) By:--------------••-------------------------- ----------------------------- I� ----------------------(Title)---- (Plot plan, showing size of lot. location of system in I ionl'to Wells, buil'ings, etc., can be placed on reverse side). .il: FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY----------------- ---- -- --------------------------------- DATE REVIEWED BY -------------------�M--- :----------------------- ----- DATE BUILDING PERMIT ISSUED--------------------------------------- - -- - -- A_---------------------------------------------- DATE.---- --------- Alterations and/or recommendations------------------------------------ -I--------------------------------------•--------------------------- II ' ------ ------------------------------- 1 ------------------ -------------- --- --------- ----------------------------------- ^�� --- FINAL INSPECTION BY:.. -- -- Date ----- --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street. 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California �w ES-9-2M �0-52 Revised W-2100