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APPLICATION FOR SANITATION PERMIT Permif No. fo Com(Complete in Duplicate) { p Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describecl.'V--- This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------------- - , -- `'"----------------- - -� Owner's Name Q � .S / ------------------------------- Phone._s — __ _.. Address - � _Z------- ---_--- :�. - 5�A-----•---------------------------------------------------------------••---------- --- Contractor's Name--------------- ��------ - --------------- Phone----- �a Q _ Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---4--- Number of bedrooms .3-- Number of baths __l_.._ Lot size _ 4 -______-- Water Supply: Public system ❑ Community system ❑ Private ❑' Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ etOpz_� Z4-:a4-`C—►� - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer is available within 200 feet) Septic Tank: Distance from .nearesr well - -1.�_---___bistance from foundation- f Material_--- -`c -"-oO No. of compartments �� g A ------ -----------Size__-,---- ------�Liquid depth_�.�------------ - Capacity------- ........ `! f os eId• Distance from nearest well- __`..-.Distance from founda 'on__ ____p_-_.--.-_.Distance to nearest lot line____--------- V Number of lines_______ ______ ------ ------------Length of each line---0_Q_'"--------------Width of trench..... f�_ __.___..� ' r L /t �/ ` . Type or filter material--1_k_-:-_ -k------Depth of filter material-------/f---------Total length___.Nth_'•-------------------------_ 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------------------------------_--_-_ I' ❑ Size: Diameter-------------------------------------Depth-- ----------------------Liquid Capacity---------- --`--� '�'g Is Privy: Distance from nearest well-------------------------------------------------Distance from nearest Building--------------------------- --------------- El -----------------------• -------------. ' ❑ Distance to nearest lot line----- ------------------------------------------------------------------------------------------------------------------------------------. l `;a Remodelingand/or repairing (describe)-------------- ------------------------------------------•-•-•--------------•---•-------------•-- --------------------------------------------------- ---------------------------------------------------------------------------------- -----------------------gerf ---------------------•-----------------•----------------------•---------•---•--------------------------------------------------------------------------•-•-------------------------------- I herebythat )have re ared this application and that the work will be done in accordance.with San Joaquin County.- ordinances, s, an rules regulations of the San Joaq in_.Local Health District. 5s ned .{ .g )---:---- ---- --- ----------------------------------------------- -- �, Con rat By-------- - - I5 -- re = = - .:o- t tor) r , (Plot plan, showing size of lot, location of syste lation to wells, build gs, efc., can be placed on reverse side). + OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- ------ ------------------ ------------------------------------ DATE------- r a REVIEWEDBY--------------------------------"-------------------------------------- ---------------------------------------------------- DATE BUILDING PERMIT ISSUED-----------------------------------------------------------------------------------"- ••----------- DATE -- F- Alterations and/or recommendations-------------------------------------- - -"------- --------------------•------------------------ -•- - ----------•-- •------------•---------- ------------ ------•--------------------•- ------------------------------------------------------ ---------------------------- ----------------------------------------------- FINAL INSPECTION BY-- --------- - --- - ^ "----------- Date_..., E 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 �f. ES-9-2M i6-52 Revised W-2j10o