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APPLICATION FOR SANITATION PERMIT Permit No. .._G. .7........ (Complete in Duplicate) Date Issued ---------- Applica;-ion is hereby made to the San Joaquin Local Health District for a ermit to construct and install the work herein-.described. This application is made in compliance with County Ordinance No. 549. ��/�. t f I� # JOB ADDRESS AND LOCATION...... trt Q = �- �7 ' K -�`� e ! Owners Name--- V..�� ' -*� �----------------- ---------------------- Phone------------ Address............ .. __IF'1...1.. ....---•-------------- Contractor's Name....... ------------------------------- ------ --- -•-- ------------------------••-------------------------------- Phone-------------------------------- � � r Installation will serve: ,Residence Tkpartmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _--- Number of bedrooms Number of baths _-_1. Lot size _.�__o_,X....__�__-�`�___ Water Supply: Public'system ❑ Community system ❑ `Private epth to Water TableCS-Of. } Character of soil to a depth of 3 feet: :Sand Gravel E] Sandy Loam -lay Loam [1 Clay ❑ Adobe❑ Hard an ❑ i Previous Application Made: Yes ❑ No [YNew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permifted if public sewer is available within 200 feet.) „ Septic Ta Distance from nearest weF.'!5� -_'Distance from foundation---I- -Material-.....................�-!..G No. of compartments.---------Z ---Size--------------------------------Liquid depth--------------------------Capacity------__ Disposal Distance from nearest well_-_V----------:Distance from foundation._ Distance to nearest lot line... .- + `� Length of each line____...._.. �`` Numbef of lines A Width of trenches /� \I�, Type or filter material. `�__"� epth of filter material------.f...� Total length------ �.... ............. Seepage Pit: ,.Distance to nearest well----------------------Distance from foundation...................:Distance to nearest lot line.---.---._.._..._ . ❑ Number of-pits---------------- Lining+material--------------..-_-----Size: Diameter------.-----------------Depth--------------- -----------'------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material -..-.-.___------..--. ...j----.-.--_. ❑ Size: Diameter------: i-----,-;---_---'----- ----Depth----------------------------------=----------------Liquid Capacity----------------------------gals Privy: Distance from nearest well---------_-.....r-------------------_------_-.____Distance from nearesf building--------------------------------------.--. r Distance to nearest'lot-line------------------------- fi Remodeling and/or repairing (describe: --------------- 1 u ------------------------------------ - ---- ------------------ ---------------------------- .--------------_-------------------- I- - 1 - -----•------------------------------------------------------------------------------------------------------------------- Lhereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reg ations of the San Joaquin Local Health District. A - = -- E ....__..... .......(Owner and/or Contractor) (Sign ctor)(Si ned)--• -- - ---- By:-----•--------------------------------------------------------- ----------------------- ------------------------(Title)---------- ------------------ -------------------------- (Plot ' plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ---------------------------------------------------------------------------- DATE----- 7 REVIEWEDBY--------------------------------------------- --------------------------------- ----------------•-----•-•-------------------- DATE-------- -------------= BUILDING PERMIT ISSUED----'...... {----------------=-----------'----------------------------------------------------- DATE------------------------------------------- Alterations and/or recommendations------------------------------------------------------------------ - • -------------- -----------_-----`------------------------•--•------------------------------ r -----------------------------------------------------------I-------- --------------------------------•--•- ----------------------------------- ---- --------------------•---- t ---------- ---------------•-----------------------------------•---------------------------------------•---- -•------ -----=-------------------------- ---------------------------------------- r --------------------------------------------------------- _ =_- ----------------------- --------------------------------- FINAL INSPECTION BY: � - Date rJ... ..: A 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 } ES- 9----2M : Revised W-2100 Y