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APPLICATION FOR SANITATION PERMIT Permit No. 'S<•-- --- (Complete in Duplicate) Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to constryct�and insta,II,t e work herein described. his application is made in compliance with County Ordinance No. S49. JOB ADDRESS AND LOCATION--------------- ____________ ✓ f Name--------------'•-------- '` ---J--f7C-f'L Q�G .------ ------------------------ Owner's -----------Phone--------------------•--------------- Address-------------------------=------...7...-�-----(�-=---- --�---------=-- ----•-'-�-----------.....------------------------------•----------------...------_------•-----------------------------•- Contractor's Name----------------------------------------- Phone. , Installation will serve: Residence Eq"Apartment House ❑ Commercial ❑ Trailer Court ❑' Motel ❑ Other ❑ Number of living units: I____ Number of bedrooms __277-"Number of baths -4----- Lot size ___`-____ -- 7e ' Water Supply: Public system Community system'❑ Private ❑ Depth to Water Table -------- ft. A Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe • _10ar- dean ❑ Previous Application Made: Yes E] No EV New Construction: Yes �No ❑ f� TYPE OF INSTALLATION AND SPECIFICATIONS: . + (No septic tank or cesspool permitted if public sewer is"available within 200-40.) Septic Tank: bistance from nearest well___' ^____Distance from foundation___ --___--Mate ial_W___ (� `______f____._____. p a N No.,of compartments--------r____------Size_.._�_xpx-s�-------Liquid•depth-------------�----------Capacity-----_�0 © - Disp sa Field: Distance from nearest we€I_ f---.._.Distance from foundation_-_._-d____--Distance to nearest lot lilir�_-��_._..- f,I� Number of lines---- --- ------ Length of each line_---------� ---�-------Width of trench---------------- ------------- T e.of filter ma__ r l b �--Depth of filter material___---'�_'—_;__Total length------------------------ Seepage Pit: Distance,to nearest wel4----------------------Distance from foundation___-______--__'_Distance to nearest lot line____---__________ , ❑ Number of pits----------------------Lining material---------------- ---- -Size: Diameter----------_-----------.Depth--------------------------------- -i ------------------------------i Cesspool: Distance from nearest well-----------------Distance from foundation_,-________________Lining material__.________.------_.____.___________. [] Size: Diameter------ -- ----------------------------Depth-----------------------"----;------ ----------------Liquid Capacity----------------------------gals, Privy. t Distance from nearest well-------------------------------------------------Distance from nearest building_____...______--_________________-_----_ r r ❑ 4 � A- A"' - Distance'to nearest lot line----- ----------- ----------------------------•--•-------- --•------•------------f------------� - - --------------------------------- Remodelingand/or repairing (describe):------- ------------------�--------------•-••-------------------------••----------------...--------------------•-------.._..---------•---••-------• - i -------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------,-- ---. ------- - --------------------------•---•-------- --•------------------------------•----------------------------------------------------•--------------- , ` � ---------------------------•--------- -----------------•--------------•--------------------•----------------------------------- ------------------------------------------------------------------------------- I f•�` hereby certify that I have prepared.this application and that the work will be done in accordance with San Joaquin'County ordinances, State laws, and- rules and regulations of the San Joaquin Local'Health District. 1 ________------h__-••- ------------(Owner and/or Contractor) (Signed}.. ------ -- ------------ -------------------------- BYz i. _ = _L7 '-------------------•---------------•----------------(Title)----------:------------•---------------------- -------i------- (Plot pla , showing size afrlot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ----- - •---------- --------- -------------•----------------------- DATE-------- - REVIEWEDBY--------------------------------------------- ---------------------------------------------------------- -------------- ----- DATE----:... `�- -- -f-w�-------- BUILDING PERMIT ISSUED---------------------- - ------ DATE------------- _i Alterations and/or recommendations------------------ _` FINAL INSPECTION BY:.._- - ------ Date - -- -- ---- 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 t