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APPLICATION FOR SANITATION PERMIT Permit No.,-:L2-s7----- (Complete in Duplicate) Date Issued San Joaquin Local Health District for permit to construct and install the work herein described. i Application is hereby made #o the Sa q p , This application is made in compliance with County Ordinance No. S49. � - JOB ADDRESS AND LO ATI N-___ -- :- ------ ------ - - ------------------------ ---------------------- - - - - ------------------ ---- - - ------- ---------- --------- - Owner's Name + -------- Phone Address ,+ /- - ---------------------------------------- --------------------•------------------------------------------------------ Contractor's Name------------------ ----------------------- Phone---------------------------------- Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motels❑ Other ❑ Number of living units: _�-_- Number of bedrooms __KNumber of baths ---L-- Lot size -------_--1-Yk- } -- -= --•- Water Supply: Public system ElCommunity system E] 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 ❑ Nox New Construction: Yes e No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted-if-public sewer is available within 200 feet.) .'! Se tic ank: Distance from nearest well__��d_--_Distance from foundation____ ___ _______Mafer' I j___ ------- No. of compartments--------_--'7C'"-___Size_ _ Liquid depth--- DisposalField: Distance from nearest ellDistance from foundation_____ -___ _ Distance to nearest to i Length of each line______ // Number of lines--_________--------_______ Q ___ __ Width of trench_______ ��,, ff 1,---.Width length ----------------- "►.. Type of filter material---- V1!1 __-Depth of filter material____ _ g AP-0 Pit: Distance to nearest well-------------------__Distance from foundation--------------------Distance to nearest lot line_-_--------.___-- [] Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- F Cesspool: Distance from nearest well-----------------Distance from foundation-----_--------_-----Lining material---------------------------------- Size: _-.--__-_---.- _--_--___--_._Size: Diameter--------------------------------------Depth----------------------------- ----- ------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well______ ________ -------------------------------Distance from nearest building--_________._______.___________-___ Al ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------�---------- v, Remodelin and/or pairing (describe):___ ...... --- - " -- - ---------=. ............ j - - -------------- ----- ----t7 vd- ------------ ------ 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. {Signed} = - ------------------------------------------ ------------------------ -----------------------------(Owner and/or Contractor) By:......:.------------------------ (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 APPLICATIONACCEPTED BY--------------------------------------- -------------------------------------------------------- DATE------------------------ 5- ................. REVIEWEDBY--------------------------------------------- -- ------ ---- -- ---------- ------------------------------------------- DATE------ �% ------- DATE-- �__ �-- - ------- BUILDINGPERMIT ISSUED------------------------------ --- -- -- - - ------------------------------------------ --------------------------- Alterationsand/or recommendations:------------- - ----------------- -------------------------------------------------------------•----------------------------------------------------•--- ------------------ �---r- --- ---------- -- --------------------------------------------------- -- '' '3----------- -------------------------------------------------------•-------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ---------------------------------------------------- ------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY------------------- -______ ___.-_ -. ---- Date .- `� --s~3-------------------------- 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 LS-9-2M 5-51 Revised W-2100