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APPLICATION FOR SANITATION PERMIT Permit (YY I (Complete in Duplicated Date Issued -y " r Applica-%n 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 Ordinance No. 549: f ,, JOBADDRESS AND LOC ATION----••-•------ X6_ 5------------ ---------- ------ ----------------•--------------------•-------------------------------------------•------- h ,. Owner's Name--------------------�`-----------•-----•----•- - ---3-'---------w��-�-�'---------------- ---- ------------------------------------- Phone--------------- -----------•------- p --- -----------------•-----------•------•-•-----------•-----•--------------------------•-------•------------------------ Address_________________ � - - - Name--- �� y Phone. ---------------------------- Contractor's Installation will serve: Res� ence .KApartment House [ICommercial ❑ Trailer Court E] Motel,0 Other [3 Number of living un� s: _____._ Number of bedrooms -- _. Number of baths -------- Lot size ____-- -�_________________._ Water Supply: Public system �` Community system ❑ Private ❑ Depth to Water Table ._______ ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ElClay Loam ❑ Clay [3 Adobe Hardpan E] Previous Application ado, Yes ❑ NoX New Construction: Yes,' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank o. i esspool permitted if public sewer is available within 200 feet.) �h Septic Tank: Distance from nearest weh___ - _Distance from foundation_-____i�__._.____.Materi yL_____ G_.___-___ �- -------- xG .--Liquid depth--.-----Noofvomparfrnents-_ ...-.-Size----- - f ! ------------Capacity----- Disposal � ' ! f Field: Distance from nearest well.___-....._Distance from foundation__---)' -_------Distance to nearest lot line--- -------- 4 of lines------------ �1 ------Length of each line-- -- h of trench------- / ---------------- r___________________TYpe filter �� De th'of filter material___.__�9_ii-....___Total length------------1_ A Seepage Pit: Distance to nearest well-_-----_________._--Distance from foundation--------------------Distance to nearest lot line_-___--_______--. ElNumb'r of pits-------------- -------Lining material----- -----------------Size: Diameter----------------- ----Depth-------•- ----------------------- Cesspool: DistaA e from nearest wO-----------------Distance from foundation--------------------Lining material_---------..__._____.__________-_____ ❑ Size: Diameter--------------------------- ----------Depth--------------------- ------- ----------------Liquid Capacity----------------------------gals. G III4 1 Privy:: Disfance rom nearest well------------------------J:-- ------Distance from nearest building----------------------------------------- ❑ DistaAe to nearest lot line--------------- ---------------- ------------------------------------------------ --------------------- a Remodeling and/or repairFing (describe):-------------------------- - -----------••---------------------------------------- — ---------------------•---------------------------;----------------- ----------------------------------------------------------------------------------=-------•--------------------• V 1 hereby certify that�{ have prepared this application and-----••-•--.--•--•.------•••-------•---------------- ----- ---------------�=------------------------------- . ------------------•------.--------- -------I--------••--------------- -----------------•------- ----- --- --- - - •------ - ---- ------ -----fir-- -------------------q-- y y ,,I p p pp that the work will be done in accordance with San Joaquin County ordinances,;State'la ,-a rules and re ulations of the San Joaquin Local Health District. / ------------------ -------------------- -------------------' --------------------- - (Owner and/or Contractor) (Signed)" BY. `� ------------ ---------- -------------------------------------------------------------(Title)--.------------------------------------------------------------- (Plot piaW�howing size oAot, location of system in relation to wells, buildings, etc', can be placed on reverse side). F FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY------------------`-----`-- :.... ,% DATE -� �' ------- r ✓ DATE - REVIEWED BY--------------- 1111 ------ BUILDINGPERMIT ISSUED------------_----------- --------------------------------------------------------------------------- DATE--------------------•---------------------------------------- 1111 Alterations and/or recommendations------------------------ --------_---- --- --------------..---------------------------------..-...-.---•------------------------------------------------ ------------------------------------------ ---------------------------•---------------.----•-•-------.------------------------*---- - ----------------------------------- ------------------------------------- •------------•-•-----...---- •---------- ---------------•--------------------------------------------------•-------------•--- ---------- ------------------------- II�-..-- ----------------- -------- ----------- -------------- -------------------- ------- ----------------------------------------- ------ ---- - ------------------ - ------------------------- --------------------------------------------------- ------------------------- FINAL INSPECTION BY:...__-.�----------------�-- ---- �•�� --- Date-------------------- ----------------- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT I I F 132 Sycamore Street 014 North "CA,' Street 130 South American Street 300 Wast Oak Street Y Stockton, California I Lodi, California Manteca, California Tracy, California , I Es-9--2M 145446 ATWQO❑ 2-54 ill'