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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued __- J53 Application is hereby made to the $an 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-----r�f__------ -------- ----------------# ------------------------------------------------------------------------------------------- ----------- 16 10 Owner's Name....-- -----!I:i G--------r ......2.t/ ------ ' - ------------------------------ Phone----•-----------------------••---- Address = --- • ---- -•-- ------•-- ----- ------------------------------------------ --- Contractor's Name.-- -- --- =----- ----------- Phone-/ Q/.L._.------ Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _--L Number of bathsy4'- Lot size _ oj�!------------------------------------------------ Wafer Supply: Public system 4_ Ominunity system ❑ " Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay ❑ Adobe A-111ardpan ❑ Previous Application Made: Yes ❑ No 'New Construction: Yes ❑ 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 wellzx{_-Distance from foundation_.-,ol� ---- -..Material-i____________________-.- --------___-_-_--_--. No. of compartments------ ------------.-,.--Size-------------------------------Liquid depth--------------- ---------Capacity---------------------- Disposal Field: Distance-from nearest .wellDistance from foundation---LOr______.Distance to nearest lot line_�..____. Number o-i lines--------------/_ Length of each line---------- Width of trench---C�--__-----.-_-_--._._-_---- Type of filter materiaL�__ _ Depth of filter maeriaL______________________7otal length------------------------------------------ Seepage Pit: Distance to nearest we�--__Distance from foundation----_- ---a......Distance to nearest lot line_./!�!.1-_-_ �– Number of pits-------/-----------Lining material_4� _.Size: Diameter- -111............Depth--ad---r-------------------� Cesspool: Distance from nearest well-----------------Distance from foundation___.--r..__-_-----.Lining material------_-.__-______._-____.__.____--. • ❑ Size: Diameter----- ------------------------------ Depth------------------------------------------------ --Liquid Capacity---------------------------gals. Privy: Distance from nearest well-_--.-.--._--_._..______-_-_-----------------Distance from nearest.building_----_._-------__-----__--_--::__-_-----.�� ❑ --- ----------• ------------------ _ ,•Distance to riearestklo"t'line.`""'� - -'- - -T---------------------------------------•-•----------- -------------------------------- Remodeling and/or repairing (describe)-------------•-------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------•--------------------•---•-----------------------------------------------------------------------------------•--------------------------------- 1 hereby certify that I have prepared this application and fhaf the work will be done in accordance with San Joaquin County ordinances, St a laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ----- •--- -- -- `---------------------------------------------- >i0t ) • - --- --------- - -- --�'�----- ----------------- wn 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 APPLICATION ACCEPTED BY:-.-.----------------------------- ----- Y -------------- .---------•-------------"-- DATE------ ------------- REVIEWEDBY------------------------------------ ------------------------------------= -------------------------------------- DATE-------------------------------------------- -------------- BUILDINGPERMIT ISSUED------------------------------------ ------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-_------------------------ ------------------------------------------------------=--------------------• -----•---- --...----------•-------------------------- -------------------------------•---------------•----•--------- --------------- -----------------------------------------------------------------------------------•----------------------------------------------------------- ----•-------------------------------------------------------------------------------------------------------------- ------------------------------r--------------------------------------•------------- FINAL INSPECTION BY:_ t " .-- Date_ .__-_--- JA Jv . 9 3 ` _ - --- ---------------------- I--- ---------------- 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 10-52 Revised W-2100