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APPLICATION FOR SANITATION PERMIT Permit No. •- -� - (Complete in Duplicate) Date Issued Application 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. JOB ADDRESS AND /LOCATiON...�'"`' � ✓ � . -------------- ------------ ---- -- � --------- IL--------- --------IL--------- ---------------Phone.-------------------•-•--------- Owner's Name �-- r. --71_1N Address------- -------46---�Z--------------�- ------------- - -o ....... - Contractor's Name-----•----------- - -W AV16"`--------------------------------------------------------------------------------------------- Phone..-.?...O�------- Installation will serve: Residence Z}i Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/--- Number of bedrooms _/``_ umber of baths --/____ Lot size ---------f-_Q --X - 1.-�--- •---- r i Water Supply: Public systeCommunity system , i Private F1Depth t_o Water Table a�Q ft. Character of soil to a depth of 3 feet: Sand Gravel 0 Sandy Loam Clay Loam }Clay El Adobe L] Hardpan El Previous Application Made: Yes E] No New Construction: Yeso - ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septic tankcesspool p u is sewer available within 200 feet.) Se tic Distance from nearest well_ Distan e from foundation______/_C1_......Mat er ai___.__._.!_1.. .�J_..___�Nr� No. of compartments------------�---------Size�'�.)1 ��_.�-_-._--Liquid depth_------�--------------Capacity...�C�-� -_.--•� Disposal ield: Distance from nearest well_________________Distance from foundation___ _ ---------- to nearest lot line.__l Number of lines------------------ _ __f Length of each line________ _ _____ Width of trench....iz-s __.__Typeof filter material____f�_��_ __:-Depth of filter material___. _.._._.-_._Total length----------- ____----._ Seepage Pit: Distance to nearest well_________________Dista nce 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-______.____...____.____...________. ❑ Size,Diameter -�.Depth:�------------ ------------------------------------I q*id Capacity-----------------------------gals. Privy: Distance from nearest well-------------------------------------_-----------Distance from nearest building____.____________________________.____. ❑ Distance to nearest lot line--------------------------------------------- - -••-------------------- ----------------------------------------------------------- -- --- N Remodeling and/or repairing (describe):-----------------------------------------------------•--•--•---------.-.....--•------------------------------------------------------------------------� F ------------------------------------------•----- ----------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------'----------------.------------"------------------------------..._..- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat�1 , and rules and regulations of the San Joaquin Local Health District. (Signed) ____ Z----------------------------------------------------------__-Owner and/or Contractor 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 1711S APPLICATION ACCEPTED BY-------- --- ------------------------------- -------- --------------------- DATE--------------------------------------- REVIEWEDBY------------------------------- ---------------------------------- ----------- -----•---------------------------------------- DATE------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- Alterations and/or recommendations-------------------------------------------------------------------- ----------------------------------•------------------------------------ -------------- -----------------------------------•--------•-------------------------•-----.-----------•-----•----------------------- ( --------------------------------------------------------------------------------•----------------------•-----•---------------------------------------- k _______________________________________________________________________________________________________________________________ __________________________________________________________ -----------------------------------------------------------.________..---.---.-____..__.______.._______ ------------------------------------------ FINAL ____-______..__________.___.._-___-- -_..-_ FINAL INSPECTION B ----- ----- - ------------------------------------- Date--------- - _..-_----�---- / ----�------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North •'C" Street r Stockton, California Lodi, California Manteca, California Tracy, California I ES-9-2M +052 Revised W-2100 �