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°=� Permit No. APPLICATION FOR SANITATION PERMIT ' (Complete in Duplicate) Date Issued ___tf' _--_S'7' r 3 Applic ,on is hereby ma a to the San Joaquin Local Health District for a permit to construct and install the work herein cribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION....________ d----*�---� --------------------- ---- .---- =' ---- OwnersName- --------------•---•--•-----.....----••----...- -- ---- ' Address - -----••-------------------4- ---•- Phone__ 6.�- ------------ a `� `' ------------ ----- f-� Contractors Name--- �----------------•--•-------...------•------• --- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:t____ Number of bedroomsAl-- Number of baths Lot size ___ ___._____ -- ----------------- i Water Supply: Public system j< Community system ❑ Private ❑ Depth to Water Table felt. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Cla ❑ ////Clary ❑ AdobeHardpan ❑ I Previous Application Made: Yes ❑ No New Construction: Yes ❑ No � �� . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tanVor cesspool permitted if public sewer is available within 200 feet.) eptic Ta Y Distance from nearest well-----------------Distance from foundation--------------------Material_________----__.__-___.__._---------._--------"�r Liquid depth--------------------------Ca acit No. of compartments---- ------------------Size-------------------------------- P Y----------------- ----- osal F- Distance from nearest well_____...__-___._Distance from foundation___________________Distance to nearest lot line---------------_ A -i Number of lines-----------------------------------Length of each line - Width of trench - \I Type of filter material------------------- -----Depth of filter material-----------------------Total length---_----.__---------_---------------- `� l�..___.Distance to nearest lot line_-_/_©-_0-1 ---- Seepage ___Seepa a Pit: Distance to nearest well__[7___ ____________Distance fr fo ndation___ -� Number of pits----I---------------Lining materia--Size: Diameter_sa1_ss----------- Cesspool: -- -Cesspool: Distance from nearest well________________ Distance from foundation--------------------Lining material---._______.________----.____________ ❑ Size: Diameter------------------- -----Depth---------------'------- ----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well______________________________________ ---------Distance from nearest building-------------"------__-------------------- ❑ Distance to nearest lot line-------------------------------- ----------------------------------------------------------- Remodeling and/or repairing (describe):-------------------------------------------------- ------------------------------------- ------------------------------- -------------•---------------------------••---------- : . --------------------------------------{-----------------------------------------•----------------------------------•-----•--------•---------------------•-------•----------•------------------------------------ I hereb ertify that I have prepare this application and that' the work will be done in accordance with San Joaquin County ordinances State laws, nd rul and re lations of the San Joaquin Local Health District. (Signed - - - -------•---------------- ------------------------- --- { Contractor) BY� ----=- ------------- -- ----------------------(Title)--- r%le" - ' "4 ------------------- (Plot plan, showing size of lot, location of system i relation to wells, uildings, etc., can be pla ed on reverse side). FOR DEPARTMENT USE ONLY ---- --------------------------- DATE---------- 55------------- APPLICATION ACCEPTED BY---�---- --------�-----�-- ---------�-- --------�-� --- �� ----- REVIEWEDBY---------- -------------- ---•----------------- . DATE-------------------_--------------------------------------- BUILDINGPERMIT ISSUED------------------------------------- -------- ------------------- DATE--------------------------------------------- ------•-------- Alterations and/or recommendations---------------------- ----------------------------------------------------_.--.---------_-----------•- •----------------_ ------- -------" s �/r Yl�u�ly J Z z-� �� FINAL INSPECTION -BY------- --------------------------------------------------------- Date_ ..... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M Revised W-2100 _ _