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1~ APPLICATION FOR SANITATION PERMIT Permit No. __ � /-.- -•• (Complete in Duplicate) Date Issued ---- Applicaa-ion 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 Ordinnaa ce No. 549. JOB ADDRESS AND LOCATION f ,'-'-of -`----•-------------------•----•----------------- Owner's Name------ s_.c d ... Phone_ Address..---------------------------------- --------lt�cm --------- -•-----------------•----------•-•----------••-------------------------------------//-------------------•------••- Contractor's Name----------------- ------ ---- - n Phone_�Td.__ p _--- - ± Installation will serve: Residence {Apartment House ❑ Commercial ❑ Trailer .Court ❑ Motel ❑ Other ❑ �i .r �o P�rs�� . Number of living units: _1---_ Number of bedrooms ______-Number of baths ---_ Lot size _--____ _ _ _______________________ Water Supply: Public system �ommunity system ❑ Private [] Depth to Water Tableft. -f—' Character of soil to a depth of 3 feet: Sand Gravel Sandy Loam Clay L am ❑ Clay ❑ AdobeI"ardpan E] ElE] ❑ Previous Application Made: Yes ❑ No W,-;<w Construction: Yes ❑ No ❑ T F INSTALLATION AND SPECIFICATIONS:' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) $ Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- No, of compartments-- - -------- ------------size-------- -------------------I...Liquid depth----------------------------:Capacity-----------•----------- osal Distance from nearest well-----------------Distance from foundation---____--------.-_.Distance to nearest lot line----------------- ! Number of lines---------=-------------------------kengfh of each line-- = --.Width of trench. Type of filter material____._.__. _. Depth of filter material-______ �7otal length______________________________________ Seepage i't:Y rDistance to Weare}t W611 .. fr o, da _ ®-_Dist nce�to nearest loyt line_W_/0 . [3 Number of pits---I-------------------Lining material.- ---- "------ - -Size: Diameter 3 Depth__11-j -------------- Cesspoo4: Distance from nearest well-----------------Distance from foundation----------------------Lining material--.________-------------_-:--._-____ Q ❑ Size: Diameter---- --------------------------Depth---------------------------•------------------- :--Liquid Capacity----------------------------gals. Privy: Distance from nearest well---,-,-----------------------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line---`K':_____________ __ Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------...----------------•---------------•------------------- ----•---------•----------------------- ---------•-•--•---------------------------_.... ---------•--------------------------•---------•-- __--------------------------•------------------------------- 3 -------- ------------------------------------------------------------------------------------------- l -------------------------------------------------------------------- `V- { . __________--------______ _____________________________________________________________________________________------------_----------------------------_------------------------------------------------------------ I heregy certify that I �ve,re 'h� ps as plication and at the work will be done in accordance with San-Joaquin County ordinances, s,=,pnd ules and egulations of the San aq ' Local ealth District. (Signed) r� -------- -------------------- --- ---- ------- -- -- ��bx�op Contractor) ----- ---- > Title (Plot plan, showing size of lot, location of system in rel t'on to wells, buildings, etc., can be p ed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- ------- ------ ------------------------------------------------------• DATE-------- >.-..------ ---------Z----,- ------------------------------------------ - REVIEW ----------------------- REVIEWEDBY------------------------------------------- -- -- ---------------------------------------------- --------------- DATE---------- ----- -------------- BUILDINGPERMIT ISSUED----------------------- ••--- --------------------------------------------------------------- DATE------------------ ------a ----------------------------- Alterations and/or recommendations: ---------- ------- ------------------•------------•--------------------------------------------------------------------------•----•------------ _.._. -------------------------------------f.______-_---_-_----.__-_--__.-____--.------------.-_--_-----.-_-------.___-----__._-.___..___.-__._____._ _... FINAL INSPECTION, BY:._ Date-- ..---------_-- --_-- -• _ t5�- ------------------------------------ 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-4-2M Revised W-2100