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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issued -`3-/ - 53 -- 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 rdinance No. 549. / II� JOB ADDRESS AND LOG V_( -*LSI I'S vvv • Phon _~ _ /------ Owner's Name_ ' n Address_..1-��--1.. _.�l-1---------------- ne --------------- - ---------------------------- Contractor's Name__ ------- ----------- --- -- i Installation will serve: Residence si Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot?l ❑ Other ❑ Number of living units: _1--- Number of ill. ___L_- Number of baths _- __- Lot size - .�--- 1_ - -----------------•-------- 0 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 1 Hardpan E] Previous Application Made: Yes ❑ No [9/ new Construction: Yes [RI/ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: x (No septic tank or cesspool permitted 'f du ublic se er is available within 200 feet.) Septic `k: Distance from nearest welDistanc� frco�rp fou`cation�Q_________._.Materi Ir_6jv�,_�__ _______ No. of compartments--=---- ---;r�'J-----=----Sizer l-1-- - ?-------Liquid FIepth-----------`f'.---------Capacity---�1- }- Disposal' Field: Distance from nearest well rr XDistance from foundation C�r "-Distance to nearest lot lifn�-J�_____ Number of lines------ T---------- __Length of each line-------------- - �-----Width of trench_--- '�V_J"1`----------_- ---- Type of filter materi __. ,1�D p g _0- e th of filter material___.___- --___._Total length a________--------.- Seepage Pit: Distance to nearest well-.---VIII-----_-------Distance from foundation-------------------Distance to nearest lot line----------------- ----------- El _.____----._____ ❑ Number of pits--------------------RLining material---------- ------------Size: Diameter-----------------------Dept'ri---------------------- - Cesspool: Distance from nearest well��_------------__Distance from .foundation---------------------Lining material__.._---.--__________-_---___.___-__. ❑ Size: Diameter-- ----- --------=s_.---Depth----•--= Liquid Capacity-------------- -------------gals. l - Privy: Distance from nearest we41-_------------'---.-:`=------------------------------Distance from nearest building------------------------------------------- Distance to nearest lot find----- ------•----------------------------------------------------------------------------- Remodeling and/or repairing (desc�ibe):__________ ------- "--------- 1 ------------------Q--- ---------------------------------------------------------------------------------------------------------------•--------- l' ---------------------------------------------- --------------- --------------------------------------------------------...Q� ------------------------ ----------- ----------------- ------------------------ ------------------- o hereby certify A have prepar this'I plication and that the work will be done in accordance with San Joaquin ounty ordinances, e a s an gulaf s of the San Joaquin Local Health District. --------------------------------------------------------(Owner and/or Contractor) {Signed) ------------ ------- - --------------- ------ " ---------- -------------------•-------------- Tl+le -- - - -- - --------------------------------------------------- (Plot plan, showing size of lot, location of syst�h in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY z _ -p DATE____�- --------------------------------- --------------- REVIEWEDBY-------- ----------------------------------------------------------------- - DATE. --------------------------------------- BUILDING PERMIT ISSUED:--------------- -- ------- ---------------------------------------------------------------- DATE------- ---------------•----------------------------- Alterations and/or recommendations:----------------9----------------__-----_-------------------I---------------- ----- ---------------------------------------------------------------------- II ------------------------•-------------------- --------•------------------------ ---------- - -,III------------------------ --• ------------ -- -------------------------- ---------------------• -------•-•--------.-. ---- ----- ------------- --------------------- +rte---------- --------------------------- FINAL INSPECTION BY:----- -- - _. Date----- -- ----- ----- s SAKI JOAQUIN LOCAL HEALTH DISTRICT Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street 132 S y Stockton, California Lodil California Manteca, California Tracy, California I ES-4--21A IC-52 Revised W-2140